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WORKS    BY  SIR  B.  G.  A.  MOYNIHAN 


Retroperitoneal  Hernia.     London,  1899 
Bailliere,  Tindall  &  Cox 

The  Surgical  Treatment  of  Gastric  and  Duodenal 
Ulcers.  W.  B.  Saunders  &  Co.,  1903 

Gall-Stones  and  their  Surgical  Treatment 
Second  Edition,  1905  W.  B.  Saunders  &  Co. 

Abdominal  Operations 
Third  Edition,    1914  W.   B.  Saunders  Company 

Duodenal  Ulcer 
Second  Edition,  1912  W.  B.  Saunders  Company 

Pathology  of  the  Living  and  other  Kssays.     W.    B. 
Saunders   Company,  1910 


WITH    MR.    MAYO    ROBSON 

Diseases  of  the  Stomach.  Second  Edition,  1905 

Diseases  of  the  Pancreas.     W.    B.  Saunders  &  Co. 

1902 


ABDOMINAL  OPERATIONS 

VOLUME  I 


BY 

Sir  BERKELEY  MOYNIHAN,  M.S.  (London),  F.R.C.S. 


LEEDS,   ENGLAND 


Third  Edition,  Revised 


Fully  Illustrated 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1914 


Set  up,  printed,  and  copyrighted,  August,  1905.      Revised,  reprinted,  and 

recopyrighted,  September,  1906.     Revised,  reprinted,  and  recop}- 

righted,  October,  19 14 


Copyright,  1914,  by  W.  B.  Saunders  Company 


Registered  at  Stationers'  Hall,  London,  England 


\o 


PRINTED    IN     PHILADELPHIA 


TO  MY  WIFE 


PREFACE  TO  THE  THIRD  EDITION 


The  Second  Edition  of  this  work  has  long  been  out  of  print. 

For  this  edition  a  considerable  revision  has  been  necessary, 
and  certain  chapters  have  been  entirely  rewritten.  I  have  kept 
strictly  to  the  original  purpose  of  the  book,  and  describe  in  detail 
only  those  operations  and  methods  which  are  practised  by  myself. 
There  are  certain  disadvantages  in  this  course,  but  I  have  always 
felt  that  what  is  chiefly  needed  in  medical  literature  is  the  direct 
expression  of  personal  opinions,  methods  and  results. 

I  am  under  many  obligations.  My  debt  to  the  surgeons  of 
America  is  too  considerable  for  repayment ;  I  can  only  most  grate- 
fully acknowledge  it.  Among  those  whose  work  and  writings 
have  been  a  constant  help  and  inspiration  to  me  are  Dr.  William 
J.  Mayo,  Dr.  Charles  H.  Mayo,  Dr.  John  B.  Murphy,  and  Dr. 
George  W.  Crile. 

My  colleagues,  Mr.  Harold  Collinson  and  Mr.  L.  R.  Braith- 
waite  have  helped  me  in  many  ways.  The  final  effort  to  complete 
the  work  was  made  easier  by  the  willing  help  of  Mr.  E.  Tissington 
Tatlow. 

The  illustrations  are  almost  exclusively  the  work  of  Miss 

Ethel  M.  Wright. 

Berkeley  Moynihan. 

33  Park  Square,  Leeds 
October,  1914 


PREFACE 


In  this  volume  I  have  included  only  those  operations  which 
are  common  to  the  two  sexes.  No  gynaecological  operations  are 
described. 

The  surgery  of  organs,  such  as  the  kidney  and  the  bladder, 
which  is  partly  intraperitoneal  and  partly  extraperitoneal,  is 
not  included,  nor  are  the  various  operations  for  hernia. 

The  operations  described  are  those  in  general  use,  and  all, 
or  almost  all,  of  them  are  those  practised  by  myself.  Some 
comment  will  doubtless  be  made  on  the  fact  that  there  is  no 
detailed  reference  to  any  mechanical  appliance,  button  or  bobbin, 
for  intestinal  anastomosis.  This  omission  is  made  deliberately, 
for  I  believe  that  the  purpose  of  these  mechanical  aids  has  been 
served,  and  that  their  interest  is  now  only  historical. 

The  illustrations  are,  with  few  exceptions,  original,  and  have 
been  drawn  for  me  by  Miss  Ethel  J\I.  Wright.  I  desire  to  ex- 
press my  thanks  to  her  for  her  careful  and  successful  work. 
In  preparing  the  subjects  for  illustrations,  and  in  the  laborious 
task  of  reading  proofs,  I  have  received  great  help  from  Mr. 
W.  Gough,  F.R.C.S.,  and  Mr.  H.  Upcott,  F.R.C.S. 

I  am  greatly  indebted  to  my  secretary,  Miss  A.  M.  Harrold, 
for  help  at  all  stages  of  the  work. 

Berkeley  Moynihan. 

33  Park  Square,  Leeds 


13 


1 6  CONTENTS   OF   VOLUME    I 

CHAPTER  XII.  PAGE 

Operations  for  Chronic  Gastric  Ulcer.     Gastroduodenostomy 240 

CHAPTER  XIII. 
Excision  of  Gastric  Ulcer 258 

CHAPTER  XIV. 
Operations  for  Hour-glass  Stomach 276 

CHAPTER  XV. 
The  Operative  Treatment  of  Cancer  of  the  Stomach 285 

CHAPTER  XVI. 
The  Choice  of  Operation  in  Cancer  of  the  Stomach 318 

CHAPTER  XVII. 
Oomplete  Gastrectomy 332 

CHAPTER  XVIII. 
Gastrostomy 350 

'  CHAPTER  XIX. 
Jejunostomy 363 

CHAPTER  XX. 
Gunshot  Wounds  of  the  Stomach 369 


SECTION  III— OPERATIONS  UPON  THE  INTESTINES 

CHAPTER  XXI. 
Intestinal  Localisation 375 

CHAPTER  XXII 
Intestinal  Suture 384 

CHAPTER  XXIII. 
Enterotomy  and  Enterostomy 406 

CHAPTER  XXIV. 
Colotomy 417 

CHAPTER  XXV. 
Entero-anastomosis,  Lateral  Anastomosis,  or  Short-circuiting  ...   433 

CHAPTER  XXVI. 
Enterectomy 440 

Index  of  Names 471 

Index  of    Subjects 477 


ABDOMINAL  OPERATIONS. 


SECTION  I. 
GENERAL  CONSIDERATIONS. 


CHAPTER  1. 
THE  BACTERIOLOGY  OF  THE  STOMACH  AND  INTESTINES. 

Many  of  the  problems  connected  with  the  surgery  of  the 
stomach  and  intestines  depend  for  their  elucidation  upon  a 
knowledge  of  the  bacteriology  of  the  alimentary  canal.  This 
subject  is  one  still  in  need  of  further  investigation. 

Billroth  in  1874  was  the  first  to  recognise  that  the  intes- 
tinal contents  of  the  newborn  are  always  sterile,  and  that  the 
yellow  stools,  coming  a  few  hours  or  days  after  birth,  are  the 
first  intestinal  discharges  to  contain  micro-organisms.  Popoff 
and  others  shewed  that  the  appearance  of  the  bacteria  in  the 
motions  depended  upon  the  time  at  which  the  first  nourish- 
ment was  taken.  The  exact  origin  of  the  Bacillus  colt,  which 
is  the  constant  inhabitant  of  the  intestinal  canal  in  man,  has 
never  been  satisfactorily  determined;  but  there  can  be  little 
doubt  that  the  infection  takes  place  through  the  mouth,  and 
that  the  vehicle  is  the  food.  It  is  to  Escherich  that  we  owe 
a  recognition  of  the  fact  that  the  Bacillus  coll  is  the  charac- 
teristic organism  of  the  human  intestine,  and  that  it  remains 
an  unvarying  inhabitant  throughout  life. 

A  bacterial  invasion  of  the  intestinal  canal  is  not  essential 
to  the  life  or  health  of  the  individual.  Experimental  work, 
VOL.  1—2  17 


1 8  ABDOMINAL   OPERATIONS. 

which  has  been  amply  confirmed,  has  shewn  that  hfe  may  be 
sustained  in  young  animals  whose  food  and  whose  surroundings 
are  sterile.  Nuttall  and  Thierf elder  obtained  a  guinea-pig 
from  its  mother  by  Csesarean  section,  and  placed  it  at  once 
in  a  sterile  chamber,  supplied  with  sterile  air,  and  fed  it  upon 
sterilized  foods.  At  the  end  of  eight  days  the  animal,  which 
was  thriving,  was  killed,  and  its  intestinal  contents  found  to 
be  sterile.  Levin  investigated  the  bacterial  conditions  in  the 
intestinal  canals  of  animals  (bears,  seals,  reindeer,  etc.)  in  Spitz- 
bergen,  and  found  that,  as  a  rule,  the  contents  of  the  bowel 
were  sterile.  In  the  Arctic  regions,  of  course,  there  is  a  great 
scarcity  of  organisms  both  in  the  air  and  in  water. 

Within  the  first  few  hours  of  life  the  intestinal  contents 
cease  to  be  sterile;  organisms  can  always  be  found.  Of  these 
organisms,  tw^o  varieties  are  described — the  permanent  and 
the  transient.  The  permanent  variety  in  man  is  the  Bacillus 
colt  and  some  of  the  streptococci  group;  the  transient  includes 
any  that  are  introduced  into  the  intestinal  canal  by  the  food. 
It  is  obvious  that,  if  any  organism  whatever  be  introduced  de- 
liberately into  the  stomach  with  the  food,  it  will  remain  for  a 
shorter  or  longer  time  an  inhabitant  of  the  alimentary  canal. 
But,  as  Gillespie  and  Miller  have  shewn,  when  bacteria  are  in- 
troduced in  this  way  there  is  a  steady  decrease  in  their  numbers 
as  digestion  proceeds,  and  in  proportion  to  the  increase  in  the 
acidity  of  the  gastric  contents.  According  to  Miher,  at  the  end 
of  nine  hours  the  stomach  contains  no  organisms.  In  the  duo- 
denum the  number  of  the  bacteria  is  small ;  but,  the  further  down 
in  the  intestine  is  the  material  from  which  the  examination  is 
made,  the  more  numerous  are  the  organisms,  until  the  ileocaecal 
valve  is  reached.  In  the  large  intestine  the  bacteria  are  again 
few  in  number.  Gilbert  and  Domenici  have  represented  dia- 
grammatically  the  average  bacterial  virulence  of  the  alimen- 
tary canal  of  dogs. 

Harvey  Gushing  has  investigated  the  conditions  in  cases 
of  intestinal  fistula.     In  a  case  of  jejunal  fistula  a  glass  of  milk 


BACTERIOLOGY   OF   STOMACH   AND    INTESTINES. 


19 


could  be  entirely  recovered  within  a  few  minutes  of  its  inges- 
tion, with  its  bacteriological  features  practically  unchanged. 
The  importance  of  the  physical  characters  of  the  food  is  there- 
fore considerable.  If  the  ingesta  be  fluid,  they  are  passed 
rapidly  onwards  into  the  duodenum,  and  are  but  little,  if  at 
all,  altered  by  transit  through  the  stomach.  If  the  food  be 
solid,  it  will  remain,  perhaps  for  hours,  in  the  stomach,  sub- 
ject throughout  this  time  to  the  action  of  the  gastric  juice, 
and  when  passed  into  the  duodenum  it  will  have  the  number 

No-of germs 

her  TTfy-. 
100,000 


l^cuve  Intestine 


Fig.  I. — "Gilbert  and  Domenici's  diagram  shewing  the  relative  number  of 
bacteria  present  in  the  contents  of  different  parts  of  the  alimentan.^  tract.  The 
dogs  were  killed  three  hours  after  a  meal  of  bread  and  meat.  Examination  of 
the  intestinal  contents  at  this  stage  of  digestion  shewed  an  abundance  of  or- 
ganisms in  the  stomach,  a  pronounced  diminution  in  number  at  the  duodenum, 
followed  by  a  gradual  rise  to  the  ileocsecal  valve,  where  bacteria  flourish  in 
the  greatest  luxuriance.  When  the  large  intestine  is  reached  there  is  a  marked 
falling  off  in  the  number,  with  a  slight  rise  proportionate  to  the  distance  from 
the  caecum"   (Harvey  Gushing). 


of  its  bacteria  greatly  reduced.  Macfadyen,  quoted  by  Gush- 
ing, has  shewn  that  the  bacillus  of  anthrax,  an  organism  easily 
killed  by  the  gastric  juice,  cannot  be  recovered  from  the  in- 
testine when  taken  after  a  full  meal,  but  that  when  adminis- 
tered with  a  large  amount  of  liquid  on  an  empty  stomach, 
its  recovery  from  the  lower  bowel  is  eas3^  In  one  of  Cushing's 
cases,  the  Bacillus  prodigiosus,  an  organism  especially  suscep- 
tible to  the  action  of  the  gastric  juice,  could  be  easily  recovered 
from  a  jejunal  fistula  after  its  ingestion  with  inoculated  milk. 


20 


ABDOMINAL    OPER-\TIOXS. 


When  the  normal  stomach  has  emptied  itself  of  food,  either 
fluid  or  solid,  the  mucous  membrane  is  sterile;  the  small 
amount  of  material  that  can  be  scraped  from  the  mucous  sur- 
face contains  no  organisms.  Marfan  and  Bernard  have  shewn 
that  the  same  applies  to  the  intestine :  that  when  any  part  of 
the  intestine  has  emptied  itself  of  its  contents,  it  becomes 
amicrobic.  In  cases  of  artificial  anus  in  man,  the  distal  loop  of 
the  bowel,  so  long  as  it  remains  empty,  is  always  found  to  be 
sterile.  If  from  any  reason  the  stomach  is  unable  to  empty 
itself  satisfactorily,  leaving  always  some  food  stagnant,  the 
natural  amicrobism  can  never  be  attained.  Gushing  writes: 
"It  is,   I  believe,   dependent  only  upon  interference  with  the 


Stamcuch .  Huodsnutn    Jt^uxuint  Ileum.        Ceeum. 


KecTlutL 


Fig.   2. — Harvey  Cushing's  diagram  shewing  the  relative  number  of  micro- 
organisms at  different  levels  of  a  dog's  intestine  after  a  prolonged  fast. 


stomach's  power  completely  to  expel  its  contents  that  bacterial 
life  may  persist  in  its  lumen.  The  same  principle  holds  true 
for  the  duodenum,  and  it  is  not  improbable  that  a  similar  ami- 
crobic state  following  digestion,  with  a  canal  completely  free 
from  food  and  the  accompanying  bacteria,  may  be  brought 
about  as  far  down  as  a  condition  of  emptiness  may  be  reached 
through  fasting."  In  a  dog  that  had  been  starved  for  several 
days,  the  upper  part  of  the  intestine  was  found  sterile.  The 
accompanying  diagram  which  Gushing  gives  may  be  contrasted 
with  that  given  by  Gilbert.  It  will  be  seen  that  all  that  por- 
tion of  the  intestine  which  can  be  rendered  empty  is  by  this 


BACTERIOLOGY   OF    STOMACH   AND    INTESTINES.  21 

means  alone  rendered  sterile  also.  Conversely  in  cases  of 
acute  or  of  chronic  intestinal  obstruction  where  the  bowel 
has  been  unable  to  empty  itself  for  days  or  for  weeks,  the  in- 
testinal contents  are  teeming  with  bacterial  life ;  the  Bacillus 
coli  and  streptococci  are  often  found  in  great  numbers,  and 
their  virulence  is  extreme. 

The  conclusions  which  may  be  stated  are  as  follows : 

1.  The  stomach  contains,  immediately  after  a  meal,  a  number 

of  micro-organisms  of  different  varieties,  according  to 
the  nature  of  the  food  administered. 

2.  If  the  food  is  given  in  a  liquid  form,  it  is  rapidly  passed  on- 

wards into  the  intestine,  and  the  bacterial  forms  are 
but  slightly,  if  at  all,  affected. 

3.  If  food  is  given  in  a  solid  form,  it  remains  longer  in  the  stom- 

ach, and  the  number  of  bacteria  contained  therein  under- 
goes a  steady  diminution  until  digestion  is  complete. 
The  empty  stomach  is  then  amicrobic. 

4.  The  duodenum  is  often  sterile;    the  number  and  virulence 

of  the  bacteria  of  the  intestine  increase  in  proportion 
to  the  distance  from  the  duodenum,  and  attain  their 
maximum  at  the  ileocascal  valve. 

5.  The   Bacillus   coli  communis  is   the   characteristic   organism 

of  the  human  intestine ;  it  is  never  absent  after  the 
first  few  days  of  life. 

6.  The  stomach  and  the  upper  part  of  the  jejunum  can  be 

rendered  sterile  by  administering  only  sterilized  foods 
and  by  attention  to  the  toilet  of  the  mouth.  In  dogs, 
starvation  for  a  few  days  leaves  the  upper  part  of  the 
intestine  empty  and  sterile. 

7.  The  stomach  and  intestine,  when  their  contents  have  been 

discharged  and  they  are  empty,  are  sterile.  If  the 
emptying  is  prevented  by  obstruction  at  the  pylorus, 
or  in  the  intestine,  the  contents,  dammed  up  behind 
the  block,  contain  organisms  whose  number  and  whose 
virulence  are  greatly  increased. 


22  ABDOMINAL   OPERATIONS. 

The  importance  of  these  facts  from  the  surgical  point  of 
view  is  that  they  shew  what  is  to  be  expected  in  cases  of  per- 
foration of  the  stomach  or  intestine,  and  they  demonstrate 
the  possibiHty  of  rendering  sterile,  for  purposes  of  operation, 
the  stomach  and  the  upper  part  of  the  intestinal  canal.  For 
example,  when  peritonitis  results  from  a  perforation  high  in 
the  intestine,  the  offending  micro-organism  is  generally  a  strep- 
tococcus ;  when  the  perforation  is  low  down  in  the  intestine, 
the  Bacillus  coli  is  the  most  abundant  or  the  only  organism. 

It  is  to  Dr.  Harvey  Gushing,  of  Baltimore,  that  we  are 
indebted  for  calling  the  attention  of  surgeons  to  the  possibil- 
ity of  rendering  the  stomach  and  intestine  sterile  as  a  pre- 
paratory measure  to  operations.  He  wrote,  in  a  very  able 
paper  from  which  I  have  quoted  freely  (vol.  ix,  "Johns  Hop- 
kins Hospital  Reports") : 

' '  The  procedure  which  we  have  employed  is  simple  and 
mainly  consists  in  an  attempt  to  render  amicrobic  all  ingesta. 
The  mouth  is  rinsed  with  an  antiseptic  solution  and  the  teeth 
are  carefully  brushed  at  intervals  of  a  few  hours,  and  with 
especial  care  before  and  after  feeding.  The  stomach,  if  any 
chronic  catarrh  exists  and  micro-organisms  in  number  are 
found  present  after  a  test-meal,  is  washed  out  carefully  morn- 
ing and  evening.  Food  is  taken  in  small  amounts  and  at  com- 
paratively frequent  intervals,  from  clean  or,  preferably,  sterile 
vessels,  and  consists  of  boiled  water,  sterilised  milk,  beef- tea, 
albumin- water,  and  similar  liquids.  Patients  with  chronic 
gastritis  have  been  seen  to  gain  in  weight  under  this  regime. 
Preliminary  to  the  operation  for  from  six  to  ten  hours  nothing 
is  given  by  the  mouth,  rectal  feeding  being  instituted  if  neces- 
sary." 

Many  drugs  have  been  given  in  the  hope  that  by  their  aid 
the  intestinal  contents  could  be  rendered  sterile.  Among  such 
are  /S-naphthol,  salol,  iodoform  and  actol,  to  mention  only  a  few. 
All  have  proved  useless.  Recently  Adolph  Hofmann  ("  Mitth. 
a.  d.  Grenzgebiet.,"  1906,  Bd.  15,  Heft  5,  p.  596)  has  recorded 
a    series    of    observations    made    upon    the    intestinal    contents 


BACTERIOLOGY   OF    STOMACH   AND    INTESTINES.  23 

(recovered  from  fistulse,  colotomy  openings,  and  enterostomy 
openings)  after  the  administration  of  isoform.  This  drug  is 
administered  in  powder  or  in  capsules,  or  in  both  together, 
the  dose  being  3  grammes,  given  in  quantities  of  -^-  gramme,  within 
a  period  of  two  to  twenty-four  hours.  The  effect  was  remark- 
able and  constant.  The  number  of  colonies  that  could  be  cul- 
tivated from  the  discharge  was  enormously  reduced  in  all  cases. 
The  rapidity  with  w^hich  the  effect  upon  the  contents  was  pro- 
duced depended  upon  the  part  of  the  alimentary  canal  from 
which  cultures  were  taken.  In  cases  of  pAdoric  disease  the  effect 
upon  the  stomach  contents  was  noticed  in  a  few  minutes,  if 
the  drug  was  administered  in  powder.  Isoform  is  supplied 
in  powder  and  in  capsules,  hardened  and  unhardened, — the 
latter  dissolve  in  about  an  hour  and  a  half  in  the  stomach, 
setting  free  the  drug;  the  former  pass  into  the  intestine  where 
they  are  dissolved  in  a  variable  and  often  uncertain  time.  In 
the  intestine  an  undoubted  effect  is  produced  in  thirty  hours 
from  the  administration  of  the  dose.  Though  3  grammes 
is  the  usual  dose,  as  much  as  7  to  8  grammes  have  been  given 
to  the  adult  male  without  producing  distress.  The  symptoms 
which  come  from  an  excessive  dose,  or  from  too  frequently  repeated 
doses,  are  loss  of  appetite,  vomiting  and  a  feeling  of  sickness. 
Unfortunately  isoform  is  no  longer  procurable.  It  is  now  my 
general  practice  before  operations  which  probably  involve  a 
resection  of  the  intestine  to  give  large  doses  of  bismuth  for  several 
days  beforehand.  This  I  began  to  do  in  those  patients  who  were 
to  be  examined  by  the  x-tsljs,  and  as  I  found  the  method  of  value 
I  extended  it  to  all  cases.  One-half  ounce  of  bismuth  carbonate 
is  given  twice  daily  for  two,  three,  or  four  days. 


CHAPTER  II. 

GENERAL  REMARKS  UPON  THE  PREPARATIONS  NECES- 
SARY IN  ABDOMINAL  OPERATIONS,  UPON  THE 
CONDUCT  OF  THE  OPERATION,  AND  UPON 
THE  AFTER-TREATMENT  OF  THE 
PATIENT. 

Success  in  abdominal  surgery,  as  in  all  the  affairs  of  life, 
depends  very  largely  upon  the  observance  of  details.  In  the 
careful  examination  of  the  patient,  with  reference  both  to  the 
local  and  general  conditions ;  in  the  strict  preparation,  for  a 
few  days  before  the  operation,  whenever  possible;  in  neatness, 
rapidity,  and  thoughtful  planning  of  the  operation — in  all  these 
there  lie  the  means  and  the  secret  of  success.  With  few  excep- 
tions, the  same  technique  is  desirable  in  all  operations.  I 
propose  to  describe  the  details  which  are  carried  out  in  my 
own  operations,  first,  with  reference  to  the  surgeon,  assistants, 
nurses,  instruments,  and  dressings;  and,  secondly,  with  refer- 
ence to  the  patient. 

PREPARATIONS   ADOPTED  BY  THE  SURGEONS  AND  ASSISTANTS. 

It  is  most  desirable — it  is  even  more,  it  is  absolutely  necessary 
— that  for  the  due  observance  of  cleanliness  during  operations 
the  surgeon  should  be  properly  clad.  The  garments  which  are 
suitable  for  daily  wear  are  surgically  unclean  and  should  be 
changed  by  all  those  who  are  to  be  in  immediate  proximity  to  the 
area  of  operation. 

The  surgeon  should  be  clad  from  head  to  foot  in  spotless  steril- 
ised garments.  A  sterilised  cap  is  worn,  so  that  the  heads  of 
the  surgeon  and  his  assistant  when  they  meet  in  sharp  contact 
over  the  abdominal  wound  shall  not  scatter  hair  and  dirt  broad- 
cast.    A  sterile  coat  is  worn,  sterile  sleeves,  and  boiled  rubber 

24 


PREPARATIONS   ADOPTED    BY   SURGEONS    AND    ASSISTANTS.      25 

gloves.  Sterilised  or,  at  least,  newly  washed,  white  trousers 
and  clean  shoes,  preferably  with  rubber  soles,  are  worn.  Pre- 
pared in  this  way,  the  surgeon  is  safe  not  to  inflict  a  chance 
infection  in  any  wound.  All  parts  likely  to  be  near  the  wound 
or  to  touch  it  are  absolutely  clean. 


Fig-  3- — J^he  surgeon  prepared  for  operation  wearing  the  spectacle  mask. 

It  is  not  enough,  though  one  can  see  the  practice  every 
day,  to  wash  the  hands  and  perhaps  the  forearms  and  to  be 
content  with  this.  When  instruments  are  lying  on  a  towel 
during  the  performance  of  an  operation,  the  surgeon  may,  in 
some  manipulation,  allow  an  unclean  elbow  or  arm  to  rest  for 
a   few   moments   upon   an   instrument,    and   presently   employ 


26 


ABDOMINAL   OPERATIONS. 


that  instrument  again.  The  operator  should  be  so  prepared 
that  all  his  accessible  surfaces  are  clothed  with  sterile  gar- 
ments. Exactly  the  same  rules  apply  to  the  assistants  and 
the  nurses.  There  should  be  no  uncovered  surfaces,  which, 
by  contact,  are  likely  to  cause  infection.  Experimental  work, 
amply  confirmed,  has  shewn  that  particles  of  saliva  are 
ejected  during  ordinary  conversation  to  a  considerable  distance. 


Fig.  4. — Gauze  mask.     The  gauze  is  suspended  on  hooks  dependent  from  a 

spectacle  frame. 

The  saliva  contains  organisms  in  profusion.  According  to  one 
eminent  bacteriologist  it  is  in  this  respect  "worse  than  the 
worst  London  sewage."  Unless  the  operator  and  his  assistant, 
and  all  those  nearly  engaged  in  the  operation,  can  preserve 
absolute  silence  during  an  operation,  they  should  wear  gauze 
masks.  I  have  had  a  sort  of  spectacle  frame  made  for  me  to 
which  the  gauze  is  fixed.     The  frame  is  fixed,  by  bent  sides, 


PREPARATIONS   ADOPTED    BY   SURGEONS   AND   ASSISTANTS.      27 

behind  the  ears,  so  that  there  is  no  fear  of  the  gauze  slipping 
or  becoming  displaced  during  an  operation.  It  is  the  custom 
among  the  unenlightened  to  scoff  at  the  necessary  precautions 
taken  by  those  who  practise  aseptic  surgery ;  the  meaning  of 
the  word  "aseptic"  is  forgotten.  The  thoughtful  enthusiast 
may  console  himself  with  the  reflection  that  in  every  race  there 
must  be  some  who  lag  behind.  The  laggards,  moreover,  are 
generally  those  who  are  "quite  satisfied  with  their  results;" 
a  testimony  not,  as  it  is  intended  to  be,  to  their  results,  but 
rather  to  the  ease  of  their  satisfaction. 

Hands. — The  preparation  of  the  hands  should  be  the  same 
whether  gloves  are  worn  or  not.  It  is  almost  impossible  to 
over-emphasise  the  importance  of  thorough  cleansing  of  the 
hands  and  nails.  The  literature  on  this  one  subject  alone  would 
require  almost  a  lifetime  for  the  reading,  but  the  conclusions 
of  all  investigators  are  unanimous  in  stating  that  an  assured 
and  absolute  sterilisation  of  the  hands  is  impossible  to  obtain. 
But  there  can  be  no  question  that  a  sufficiently  near  approach 
to  perfection  can  be  attained  by  the  exercise  of  the  greatest 
care.  Professor  Kocher,  for  example,  whose  results  are  at 
the  least  the  equal  of  any,  operates  sometimes  with  bare  hands. 
But  of  the  care  taken  by  him  to  ensure  cleanliness,  all  those  who 
have  seen  him  work,  or  who  have  read  his  book,  will  realise. 
It  could,  I  think,  be  successfully  argued  that  of  all  the  details 
in  the  preparation  for  an  operation  none  equals  that  of  the 
cleansing  of  the  surgeon's  hands. 

The  preparation  begins  with  a  thorough  washing  in  soap 
and  hot  water.  When  the  hands  and  arms  are  socially  clean, 
a  nail-brush  or,  what  is  perhaps  better,  some  squares  of  sterile 
gauze  or  butter-muslin  may  be  taken  and  a  thorough  scrub- 
bing of  the  hands,  fingers,  and  nails  especially,  is  begun.  Each 
finger  and  each  nail  must  be  separately  scrubbed,  and  frequent 
rinsing,  in  water  as  hot  as  can  be  borne,  is  necessary.  If  pos- 
sible, running  water  should  be  used,  but,  failing  that,  a  series 
of  basins   will   do   equally   well.     After   prolonged   washing  in 


28  ABDOMINAL   OPER-\TIONS. 

one  basin,  a  second  is  used,  and  a  third,  and  finall}'  a  fourth. 
Each  basin  and  the  water  which  it  contains  should  be  steril- 
ised. It  is  of  no  advantage  to  have  sterile  running  water 
if  the  basin  into  which  it  runs  is  a  fixed  basin,  which  cannot 
be  rendered  sterile ;  nor  is  it  possible  to  h.a.xe  water  remain 
sterile  if  the  basin  which  it  fills  is  fixed,  as  in  the  ordinary 
lavaton'.  Either  the  water  must  be  running  continuously 
and  allowed  to  flow  over  and  away  from  the  hands  and  arms, 
or  the  basin  and  its  contained  water  must  each  be  easily  steril- 
isable.  The  washing  must  be  carried  out  regardless  of  time. 
After  at  least  fifteen  minutes  of  soap  and  water,  the  hands 
and  nails  may  be  scrubbed  with  sterile  gauze,  which  is  worked 
into  all  the  crevices  and  cracks  which  exist  on  ever}^  hand 
and  finger.  After  this,  some  antiseptic  application  is  necessary. 
The  best  is  alcohol  in  some  form  or  another.  A  solution  of 
60  to  70  per  cent,  of  alcohol  to  the  extent  of  two  or  four 
ounces  may  be  poured  OA'er  the  hands,  rubbed  well  over,  and 
wiped  off  with  a  sterile  towel,  or  the  hands  may  be  soaked  for 
a  few  minutes  in  a  solution  of  spirit  and  biniodide  of  mercur}^ 
Instead  of  alcohol  a  watery  solution  of  biniodide  of  mercur}' 
I  :  2000  with  potassium  iodide  may  be  used,  and  the  hands, 
forearms,  and  elbows  allowed  to  soak  therein  for  at  least  five 
minutes  by  the  clock.  Watery  solutions  have,  however,  a  value 
far  inferior  to  spirituous  solutions,  being  less  effective  as  germi- 
cides and  more  prone  to  irritate  the  skin.  The  great  disadvan- 
tage of  aU  antiseptic  preparations  for  the  hands  is  the  undoubted 
tendency  that  they  have  to  cause  roughness.  This  rough  and 
coarse  condition  of  the  skin  makes  any  cleansing  very  much 
more  tedious  and  any  reasonable  sterilisation  very  difficult  of 
attainment.  In  these  matters  the  personal  idiosyncrasy  of  the 
surgeon  counts  for  much.  Some  operators  can  bear  mercury 
compounds,  others  are  immune  to  the  irritation  of  carbolic,  but 
all,  so  far  as  I  can  judge,  can  bear  to  use  alcohol  preparations 
better  than  any  other  antiseptic  agent.  My  own  practice  is  to 
wash  thoroughly  in  the  way  I  have  described,  with  soap  and  hot 


PREPAR.\TIONS   ADOPTED    BY   SURGEONS   AND   ASSISTANTS.      29 

water,  to  use  gauze  friction,  to  steep  for  a  few  minutes  in  l  :  2000 
biniodide,  then  to  have  a  wash  over  with  65  per  cent,  alcohol, 
and  finally  to  rinse  well  in  sterile  salt  solution. 

Gloves. — It  is  now  my  invariable  practice  to  use  rubber 
gloves  during  operations.  At  the  first  I  found  some  difficulty 
in  working  in  them,  and  I  felt  clumsy  and  inapt.  That  was 
the  fault  of  the  gloves,  and  of  my  want  of  knowledge  of  the 
proper  method  of  putting  them  on. 

I  now  use  No.  7  or  7^  light  or  medium  rubber  gloves.  They 
are  a  size  smaller  than  my  ordinary  glove,  and  therefore  fit 
fairly  tight.  Gloves  may  be  sterilised  in  the  autoclave  or  by 
boiling:  they  may  be  used,  that  is,  dry  or  wet.  I  greatly  prefer 
the  former.  There  is  no  difficulty  in  the  dry  sterilisation  of 
gloves,  though  I  think  the  life  of  a  glove  is  shorter  when  this 
method  is  employed.  If  used  wet,  the  gloves  after  being  boiled 
for  twenty  minutes  are  put  on  in  the  following  way:  The  open- 
ing in  the  glove  is  held  stretched  wide  by  two  fingers  and  the 
glove  is  filled,  by  a  movement  of  "scooping,"  with  sterile  salt 
solution  which  fills  the  basin  in  which  the  gloves  lie.  When  the 
glove  is  nearly  filled  with  water  it  is  held  in  one  hand  while  the 
other  hand  gently  wriggles  into  it.  As  the  hand  enters,  water 
escapes  until  the  fingers  have  reached  to  within  about  an  inch 
of  the  tip.  The  cuff  of  the  glove  is  turned  backwards  and  the 
glove  is  held  from  the  inside.  It  is  only  after  the  sterile  sleeves 
have  been  put  on  that  the  cuff  is  turned  over  on  to  the  forearm. 
Then  the  other  glove  is  filled  and  put  on  in  exactly  the  same  way. 
The  further  pulling  on  of  the  gloves  is  impossible,  but  they 
may  be  made  to  go  on  by  rapidly  stroking  the  glove  from  the 
fingers  to  the  wrist  with  dry  sterile  gauze.  The  glove  when 
fully  on  should  fit  quite  tight,  but  should  not  be  so  tight  as 
to  hamper  the  movements  of  the  hand.  The  outside  of  the 
glove  should  never  be  touched  with  the  opposite  hand,  which, 
though  scrupulously  prepared,  should  be  considered,  as  it  doubt- 
less is,  capable  of  infecting  the  glove  if  friction  be  used.  (See 
Kocher's  "Operative  Surgery,"  second  English  edition.) 


30  ABDOMINAL    OPER.\TIONS. 

During  an  operation  the  glove-covered  hand  is  rinsed  in 
sterile  salt  solution  as  soon  as  soiled.  As  a  rule,  it  is  easier 
to  work  with  a  glove  which  is  wet  than  with  one  which  is  dry, 
for  when  drv,  the  gloves  are  apt  to  stick  to  instruments,  liga- 
tures, and  swabs.  A  frequent  rinsing  in  a  sterilised  solution 
is  therefore  necessary.  No  antiseptic  solution  is  ever  used, 
and  none  is  permitted  to  touch  the  peritoneum.  There  is 
abundant  experimental  evidence  to  shew  that  the  delicate 
peritoneum  is  seriously  damaged  by  contact  with  antiseptic 
solutions,  and  that  its  power  of  absorption  is  thereby  decidedly 
lessened. 

During  an  operation  a  glove  may  be  pricked  or  torn  by 
a  needle  or  other  sharp  instrument.  This  is  more  likely  to 
happen  when  the  operator  is  unused  to  gloves ;  as  he  becomes 
more  accustomed  to  them  and  has  cultivated  a  slightly  altered 
tactile  sense,  he  will  find  that  an  injury  to  a  glove  is  rarely 
caused.  If  the  prick  be  on  a  finger,  a  finger-stall  or  a  finger 
cut  from  another  glove  which  has  been  partiall}^  spoilt,  must 
be  used  to  cover  the  damage.  This  should  be  done  at  once, 
for  if  the  glove  has  been  w^orn  even  for  a  few  minutes,  the  hand 
will  be  septic.  The  sweat-glands  and  the  deeper  portions  of 
the  skin  will  have  emptied  their  organisms  on  to  the  surface 
of  the  hand.  If  a  rent  be  made  in  the  hand  of  the  glove,  a 
fresh  glove  must  be  put  on  at  once.  It  is,  therefore,  always 
necessary  to  have  a  reserve  pair  of  gloves  for  the  surgeon  and 
for  his  assistant,  and  several  glove-fingers. 

At  the  first  using  of  the  gloves  the  operator  will  doubtless 
feel  that  the  fingers  are  clumsy,  and  that  it  is  difficult  to  get 
a  proper  grip  of  any  structure.  A  little  practice,  however,  will 
soon  overcome  all  these  initial  difficulties.  If  a  flat  gauze 
swab  be  used  on  the  gloved  hand,  it  will  be  found  that  a  better 
hold  is  thereby  obtained  than  is  possible  with  the  bare  hand. 
A  pattern  of  glove  has  recently  been  sold  in  which  the  surface 
of  the  rubber  is  roughened  by  the  impress  of  innumerable  fine 


PREPARATIONS   ADOPTED    BY   SURGEONS   AND   ASSISTANTS.      3 1 

pits.  In  use,  however,  I  have  not  found  any  advantage  from 
this. 

After  the  surgeon  has  become  thoroughly  accustomed  to 
the  wearing  of  the  gloves,  he  will  probably  find  that  he  can 
work  quite  as  well  with  medium  as  with  thin  gloves. 

Assistants. — The  remarks  made  as  to  the  preparation  of 
the  surgeon  apply  also  to  his  assistant.  As  a  rule,  only  one 
assistant  is  necessary  or  desirable.  Indeed,  many  operations — 
such,  for  example,  as  gastro-enterostomy — can  be  done  with- 
out any  assistance.  A  good,  well- trained  assistant  is,  how- 
ever, a  great  help.  More  assistants  than  one  are  rarely,  if 
ever,  necessary,  and  each  one  is  an  additional  potential  source 
of  infection.  The  fewer  persons  engaged  in  an  operation,  the 
fewer  are  the  chances  of  infection.  The  nurse  or  nurses  imme- 
diately engaged  in  the  operation  are  instructed  to  prepare 
in  the  same  manner  as  the  surgeon.  A  white,  sterilised  dress 
or  overall  is  worn,  the  hair  is  covered  with  a  sterile  cap,  and 
clean,  white  rubber  shoes  are  worn.  If  a  nurse  helps  in  the 
operation  by  handing  swabs  or  sponges,  or  by  cutting  liga- 
tures, threading  needles,  or  the  like,  she  should  prepare  her 
hands  as  does  the  surgeon,  and  should  wear  rubber  gloves. 
In  these  circumstances,  she  becomes  an  additional  assistant, 
and  if  the  same  nurse  be  employed  over  a  series  of  months 
or  years,  she  will  soon  become  expert  in  her  work  and  scrupu- 
lous in  the  preparation  for  it. 

Swabs. — Swabs  are  employed  for  all  operations.  I  have 
ceased  to  use  marine  sponges  for  many  years ;  they  are  more 
difficult  and  more  tedious  to  prepare  and  are  not  so  trust- 
worthy. The  large,  flat  sponge  certainly  answered  its  purpose — 
the  protection  and  covering  of  the  viscera — rather  better  than 
any  flat  swab  I  have  used,  but  the  difference  is  only  slight 
and  is  more  than  compensated  for,  in  my  opinion,  by  the 
greater  sense  of  security  that  one  has  in  regard  to  the  sterility 
of  a  gauze  swab. 

Swabs    are    made    entirely    of    gauze    or    butter-muslin.     I 


32  ABDOMINAL   OPERATIONS. 

prefer  the  latter.  The  swabs  are  of  various  sizes  from  three 
inches  square  to  six  inches  square,  and  are  made  by  folding 
over,  two  or  three  times,  a  large  square  of  gauze.  The  frayed 
ends  of  the  gauze  are  tucked  in,  so  that  no  loose  filaments  are 
left  on  the  wound  when  the  swab  is  used. 

The  large  flat  swabs  are  made  of  several  layers  of  muslin, 
and  are  quilted  at  the  edge  in  order  to  prevent  fraying.  At 
the  comer  of  each,  a  piece  of  tape  eighteen  inches  in  length 
is  stitched.  The  whole  of  the  gauze  square  can  be  introduced 
and  the  tape  left  hanging  from  the  wound,  a  clip  being  fastened 
on  the  end.  This  method  is  the  most  satisfactory  of  all,  for, 
if  no  tape  be  affixed,  the  sponge  or  swab  must  be  kept  in  sight, 
or  a  portion  of  it  must  project  from  the  wound,  and  the  space 
in  which  the  surgeon  has  to  work  is  thereby  greatly  narrowed. 

The  small  swabs  are  put  up,  for  sterilising  purposes,  in 
packages  of  two  dozen,  the  large  ones  in  packages  of  half  a 
dozen.  The  number  of  each  size  is  counted  at  the  completion 
of  the  operation  so  as  to  make  certain  that  none  has  been  left 
in  the  abdomen.  My  own  rule  is  never,  under  any  circum- 
stances, or  in  any  operation,  to  allow  a  small  swab  to  be  left 
even  for  a  moment  in  the  cavity;  a  small  swab  is  not  allowed 
to  leave  the  hand  of  the  surgeon  or  his  assistant;  the  large 
swabs  are  introduced  in  any  number,  but  a  clip  is  at  once  ap- 
plied to  each  tape,  or  to  a  group  of  two,  three,  or  more  tapes. 
The  counting  of  the  swabs  under  these  conditions  is  not  neces- 
sary, but  it  is  as  w^ell  to  observe  the  ceremony,  as  it  impresses 
upon  all  concerned  the  importance  of  being  exact  in  such  mat- 
ters. 

For  the  last  few  years  I  have  used  in  all  operations  upon  the 
abdomen  square  sheets  consisting  of  dental  rubber  with  two  lay- 
ers of  gauze  on  each  side  infolded  and  stitched  round  the  edges. 
These  mackintoshes  are  lo  or  12  inches  square,  and  can  be  boiled 
or  sterilised  in  the  autoclave  on  a  great  many  occasions.  They 
are  used  to  cover  any  organ  during  the  time  it  may  have  to  lie 
outside  the  incision,  and  are  used  in  all  gall-bladder  operations 


PREPARATIONS   ADOPTED    BY   SURGEONS   AND    ASSISTANTS.      33 

to  wrap  well  round  the  edges  of  the  abdominal  incision.  Being 
wrung  out  of  the  hot  saline  solution  they  serve  to  keep  all  the 
parts  they  cover  warm  and  moist,  and  they  form  an  impassable 
barrier  if  any  infective  lesion  is  being  handled.  Indeed  they  are 
on  all  occasions  and  in  all  places  most  useful. 

Gauze  swabs  have  been  occasionally  left  in  the  abdomen,  ow- 
ing to  a  defective  method,  or  an  absence  of  any  method,  of  count- 
ing them  before  and  after  the  operation.  As  a  rule  the  wound 
will  stubbornly  refuse  to  heal,  or  having  healed  will  break  down, 
if  any  foreign  material  remains.  But  many  cases  are  known  in 
which  an  excellent  recovery  has  been  made  by  the  patient,  and 
a  year  or  two  later  a  second  operation  has  been  undertaken  for 
the  removal  of  an  abdominal  tumour.  A  friend  of  my  own,  a 
most  careful  and  competent  operator,  performed  an  operation 
upon  the  stomach  of  a  girl  for  a  chronic  ulcer.  A  little  over 
a  year  later  the  patient  again  consulted  him  on  account  of  a 
painless  median  abdominal  tumour,  freely  movable  and  of  smooth 
outline.  The  abdomen  was  again  opened  and  a  ' '  fibrous  tumour 
of  the  omentum  removed,  which  on  section  proved  to  be  a  gauze 
swab  completely  invested  by  the  omentum.  An  interesting  case 
is  recorded  by  Loze  ("Rev.  de  Chir.,"  1908,  i,  853).  A  woman  un- 
derwent an  operation  for  appendicitis ;  three  years  later  the  ab- 
dominal cicatrix  gave  way  and  34  strips  of  gauze  were  extracted 
through  it,  one  by  one.  The  operator  had  not  dressed  the  wound 
himself  but  ordered  that  one  strip  of  gauze  should  be  introduced 
daily.  This  was  done  most  conscientiously,  and  as  he  had 
omitted  to  direct  the  daily  withdrawal  of  the  strip,  34  were  intro- 
duced but  never  removed;  the  wound  ultimately  healed  over 
them. 

The  swabs,  after  being  made  in  the  manner  described,  are 
packed  in  a  hold-all  made  of  gamgee  tissue,  protected  on  the 
outer  side  by  brown  hoUand.  The  number  in  each  package 
is  always  the  same — two  dozen  of  the  smaller  sizes,  half  a  dozen 
of  the  larger  size.  In  these  packages  the  swabs  are  sterilised, 
three  or  four  of  the  hold-alls  being  wrapped  together  in  a  strong, 


34  ABDOMINAL   OPERATIONS. 

large  towel.  The  sterilisation  is  effected  in  a  pressure  steriliser, 
a  temperature  of  250°  F.  being  maintained  for  fort}^  to  sixty 
minutes. 

It  is  important  that  as  short  an  interval  as  possible  should 
elapse  between  the  sterilisation  and  the  usage  of  the  swabs. 
The  most  desirable,  though  not  alwa^^s  the  most  convenient, 
arrangement  is  for  the  process  of  sterilisation  to  conclude 
within  an  hoiu"  of  the  operation,  and  for  the  packages  to  be 
taken  from  the  steriliser  forthwith  to  the  operation  room.  But 
if  this  cannot  be  done,  it  is  most  desirable  that  the  interval 
should  not  be  more  than  one  or,  at  the  most,  two  days.  After 
a  longer  period  than  this  it  is  necessar}^  to  repeat  the  sterilisa- 
tion. The  same  rules  and  procedure  appty  to  the  towels  used 
during  the  operation.  There  should  be  an  abundance  of  these, 
used  to  cover  in  the  patient  completely.  These  should  be 
sterile,  and  their  sterilisation  should  have  been  recently  com- 
pleted. 

Instruments  and  Ligatures. — Everything  used  by  the  surgeon 
or  by  the  nurses  engaged  in  the  operation  should  be  steril- 
ised. Bowls,  ligature,  and  instrument  dishes,  jugs  for  saline 
solution,  and  similar  articles  should  all  be  boiled.  These  are 
often  large  and  even  cumbersome  in  size,  and  their  sterilisa- 
tion b}^  boiling  is  not  easily  effected.  I  have  a  large  copper 
vat,  measuring  two  feet  by  two  feet  by  two  feet,  into  which 
all  bowls  necessary  for  any  operation  are  placed  and  therein 
boiled  for  thirty  to  forty  minutes.  If  the  operation  should 
prove  to  be  a  septic  one,  as  in  appendix,  or  tubal,  or  gall-blad- 
der operations,  especial  care  is  subsequently  taken  that  all 
bowls,  etc.,  are  subjected  to  prolonged  boiling.  The  washing 
out  of  such  basins  with  strong  antiseptic  solutions  may  be 
soothing  to  the  conscience  of  the  surgeon  or  of  the  nurse,  but 
it  probably  does  not  much  affect  the  power  of  procreation  of 
a  pyogenic  organism.     Prolonged  boiling  is  necessary. 

Catgut. — During  the  last  nine  years  I  have  used  exclu- 
sively the  method  of   Claudius  in  the   preparation  of   catgut. 


PREPARATIONS   ADOPTED    BY   SURGEONS   AND   ASSISTANTS.      35 

The  ordinary  raw  commercial  catgut  is  steeped  in  a  solution  made 
by  adding  one  ounce  of  iodine  and  one  ounce  and  a  half  of 
potassium  iodide  to  five  pints  of  water,  for  eight  to  ten  days. 
The  crystals  of  potassium  iodide  and  of  iodine  are  together 
dissolved  in  about  two  and  a  half  ounces  of  water,  first,  and  the 
solution  is  then  diluted  to  the  requisite  degree.  The  catgut 
may  be  kept  in  this  solution  for  many  weeks  without  under- 
going any  change  for  the  worse.  It  can  be  used  on  the  eighth 
day  or  on  any  subsequent  day.  I  have  tested  this  catgut 
thoroughly  and  am  convinced,  on  experimental  and  clinical 
grounds,  of  its  sterility.  The  instruction  given  by  Claudius 
and  all  subsequent  writers  is  to  use  one  ounce  of  iodine  and  one 
ounce  of  potassium  iodide;  but  with  these  proportions  the  full 
solution  of  the  iodine  is  impossible.  Moschowitz's  modification 
of  the  Claudius  method  consists  of  placing  ordinary  raw  com- 
mercial catgut  for  five  days  in  a  5  per  cent,  alcoholic  solution 
of  iodine,  then  removing  and  storing  dry.  Catgut  prepared  in 
this  way  may  be  soaked  in  sterile  water  before  use.  I  have  tried 
this  method  but  find  that  the  results  are  inferior  to  those  obtained 
by  the  original  Claudius  method — the  catgut  being  too  brittle. 

Catgut  is  used  for  almost  all  ligatures.  If  anything  stronger 
is  needed,  then  Pagenstecher's  celluloid  thread  is  used.  This 
is  made  in  several  sizes,  but  the  thin  and  a  medium  size  are 
all  that  are  necessary.  I  use  this  material  for  all  ligatures  or 
sutures  that  require  to  be  retained  in  place  for  more  than  a  few 
days.  The  use  of  silk  has  been  entirely  abandoned  by  me  for 
some  years,  as  I  find  that  the  celluloid  thread  is  more  easily  ster- 
ilised, that  it  presents  a  smoother  surface,  and  that  it  is  far 
stronger  than  an  equal  size  of  silk.  The  breaking  of  a  Pagen- 
stecher  thread  ligature  or  suture  is  an  extremely  rare  occurrence ; 
when  it  happens,  it  is  almost  certainly  due  to  the  fact  that  the 
thread  has  been  boiled  too  often.  The  thread  when  wound  on 
glass  reels  can  be  boiled  for  four  or  five  operations,  but  after  this 
it  begins  to  fray  and  is  then  liable  to  break.  It  is,  moreover, 
then  most  unsuitable  for  sutures,  for  the  rough  surface  tears 


36  ABDOMINAL   OPERATIONS. 

the  peritoneum  as  it  is  being  pulled  through.  This  is  the  only 
fault  that  the  thread  has,  and  as  the  thread  is  very  cheap,  it 
is  better  to  throw  it  away,  after  being  boiled  three  or  four  times, 
than  to  run  any  risk  of  its  breaking. 

Drainage  Material. — During  recent  years  a  marked  change 
has  come  over  surgical  opinion  with  regard  to  the  question 
of  drainage  after  abdominal  section.  At  one  time  it  was 
considered  that  drainage  was  the  safeguard  after  all  opera- 
tions ;  that  the  provision  for  the  free  escape  of  infiammator}^ 
products  made  up  for  any  slight  fault  in  the  operative  tech- 
nique. Now,  thanks  largely  to  the  work  of  Clark  and  others 
who  have  studied  the  question  with  great  care,  we  know  that, 
when  employed  as  a  routine  measure,  drainage  is  rather  a 
means  of  sepsis  than  a  measure  of  escape  from  its  effects. 
Drainage  of  the  peritoneal  cavity  is  very  rarely  necessary. 
The  point  will  be  dealt  with  again  when  we  come  to  speak 
of  the  various  operations ;  but,  speaking  generally,  one  may 
say  that  it  is  only  for  septic  conditions  that  drainage  is  ever 
needed. 

Gauze,  which  is  so  often  used  as  a  "drain,"  is  the  worst  ma- 
terial possible  for  such  a  purpose.  Gauze  is  not  a  drain,  it  is  a 
plug.  It  may  with  advantage  be  used  when  it  is  wished  to  set 
up  a  barrier  shutting  off  a  part,  possibly  infected,  from  the  gen- 
eral peritoneal  cavity,  which  remains  unsoiled.  The  rapidity 
with  which  the  omentum  especially,  and  in  less  degree  the  in- 
testines, adhere  to  gauze  is  remarkable.  Probabty  within  two  or 
three  hours  any  area  surrounded  by  a  few  layers  of  gauze  is  thor- 
oughly isolated  from  the  rest  of  the  body  cavity.  There  are  cases, 
too,  in  which  an  oozing  surface  may  need  to  be  submitted  to  pres- 
sure to  check  or  arrest  the  haemorrhage ;  and  for  this  purpose  also 
gauze  is  more  useful  than  anything  else.  But  as  a  drainage  ma- 
terial it  is  of  very  little  value.  For  within  a  few  hours  its  meshes 
are  filled  in  with  lymph,  no  liquid  can  be  absorbed  or  transmitted 
by  it,  and  any  serous  or  other  fluid  which  may  collect  is  very 
probably  pent  up,  quite  unable  to  escape  with  any  freedom.     On 


PREPARATION   OF   THE   PATIENT.  37 

the  removal  of  such  a  strip  or  roll  of  gauze  a  gush  of  fluid  is  often 
seen  to  escape.  If  a  little  drain  is  required,  as  some  sutures  are 
required,  for  purely  "hypnotic "  purposes  (so  that  the  surgeon  may 
sleep  better  at  night),  then  a  fine  strip  of  dental  rubber  tissue  will 
be  found  the  best  material  of  all. 

In  cases  where  a  larger  drainage  is  necessary  the  split  rubber 
tube  may  be  used.  This  tube  may  be  of  any  size  up  to  a  diameter 
of  one  inch.  The  tube  is  cut  of  adequate  length  and  slit  up  with 
scissors;  the  terminal  portion  is  cut  slant-wise  in  order  to  give  a 
wide  inlet  for  the  fluid  to  be  drained  through  to  the  lumen  of  the 
tube. 

PREPARATION  OF  THE  PATIENT. 

In  all  cases  an  adequate  preparation  of  the  patient  is 
most  necessary.  There  are  certain  surgical  emergencies, 
catastrophes  like  the  perforation  of  a  gastric  or  a  duodenal 
ulcer  or  the  rupture  of  a  tubal  gestation,  in  which  the 
urgency  of  affairs  does  not  permit  of  any  elaborate  detail 
to  be  observed.  But,  whenever  time  and  circumstance 
and  opportunity  render  it  possible,  the  preparation  of  the 
patient,  both  locally  and  generally,  should  be  most  scrupu- 
lously observed.  It  is  said  by  some  surgeons  that  strict 
preparations  are  absurd,  but  there  can  be  no  question 
that  they  repay  one  in  better  results.  The  patient  should 
be  kept  in  bed  for  the  whole  of  the  day  preceding  opera- 
tion, and  for  the  afternoon  and  evening  of  the  day  before 
that.  If  the  operation  is  to  be  done  on,  say,  Wednes- 
day morning,  the  patient  goes  to  bed  on  Monday  after- 
noon. He  is  at  once  given  five  grains  of  calomel  or  any  other 
aperient  he  prefers,  which  is  followed  early  on  Tuesday  morning 
by  a  full  dose  of  saline  aperient.  Later  in  the  morning  if  these 
have  not  acted,  an  enema  of  soap  and  water  is  given,  and  if  the 
bowels  are  at  all  loaded,  or  the  patient  has  previously  suffered  from 
constipation,  the  enema  is  repeated  late  at  night.  The  condition 
of  the  mouth  receives  close  attention.     Every  patient  is  given 


38  ABDOMINAL   OPERATIONS 

a  new  tooth-brush  and  a  bottle  of  antiseptic  mouth-wash  on  ar- 
rival in  the  Nursing  Home  or  hospital,  and  the  nurse  is  instructed 
to  see  that  a  thorough  cleansing  of  the  mouth  is  observed  every 
hour  or  two  during  the  day.  It  is  astonishing  to  what  a  degree 
of  uncleanness  even  the  better  class  of  people  will  allow  their 
teeth  to  go.  Patients  with  gastric  ulcer  and  its  complications 
seem  to  suffer  especially  from  bad  teeth,  indeed  it  has  been  as- 
serted by  many  that  oral  sepsis  is  the  important  factor  in  the 
causation  of  gastric  ulcer.  If  the  patient  is  in  very  feeble 
health,  the  nurse  is  instructed  to  clean  the  patient's  mouth 
by  frequent  wiping  with  gauze  or  lint,  and  the  patient  subse- 
quently rinses  the  mouth  out.  It  is  possible,  as  the  excel- 
lent work  of  Dr.  Harvey  Gushing  has  shown,  by  careful 
attention  to  the  condition  of  the  mouth,  and  by  the  sterilisa- 
tion of  all  foods,  to  render  the  alimentary  canal  comparatively 
aseptic.  All  patients  from  the  moment  they  are  received  into 
hospital  are  fed  on  fluid  diet,  and  everything  given  is  sterilised, 
and  the  feeder  or  vessel  from  which  the  food  is  taken  is 
also  boiled. 

I  am  disposed  to  think  that  the  occurrence  of  parotitis 
and  perhaps  of  pneumonia  after  abdominal  operations  is 
largely  due  to  infection  from  the  mouth.  In  some  cases 
so  foul  a  condition  of  teeth  and  gums  may  be  accidentally 
discovered  as  to  make  a  little  delay  in  operating  imperative. 
In  one  patient  I  found,  quite  by  accident,  a  degree  of 
suppuration  in  the  mouth  and  a  foetor  of  breath  that  war- 
ranted a  diagnosis  of  Riggs's  disease.  In  such  a  case, 
and  even  in  bad  cases  of  carious  teeth,  an  aspiration  pneu- 
monia is  not  unlikely  to  occur,  or  an  extension  of  inflamma- 
tion along  Stenson's  duct,  unless  a  thorough  and  repeated 
cleansing  is  observed. 

The  skin  of  the  abdomen  needs,  and  must  receive,  very 
careful  preparation  twenty-four  hours  before  the  operation.  The 
hair  is  first  shaved  away  from  the  whole  abdominal  wall  and  from 
the  pubes.     It  is  evidence  of  careless  work  to  see  only  a  patch 


PREPAIL\TION   OF   THE   PATIENT.  39 

shaved,  one-half  of  the  pubic  hair,  for  instance,  remaining  un- 
touched. It  is  weU  to  limit  the  operative  field,  of  course,  but 
the  preparation  of  the  skin  must  extend  widely  beyond  it. 

A  free  washing  with  soap,  and  hot  water  frequently 
changed,  is  first  necessary.  The  best  material  wherewith  to 
wash  is  sterile  gauze  in  large  pads.  These  are  moistened 
with  hot  water  and  rubbed  with  soap  till  a  good  lather 
is  obtained.  This  washing  should  be  continued  for  a 
quarter  of  an  hour,  the  water  and  the  gauze  being  fre- 
quently changed.  An  antiseptic  compress  is  then  applied 
and  left  on  until  immediately  before  the  operation.  The  com- 
press consists  of  lint  of  two  or  three  thicknesses,  soaked  in  i  per 
cent,  formalin,  i  in  80  carbolic,  or  i  in  2000  biniodide  lotion.  I 
prefer  the  former  in  the  belief  that  there  is  by  its  means  a  deeper 
penetration  of  the  skin  and  of  the  glands.  Upon  the  operation 
table  the  skin  is  again  washed  with  spirit  soap  and  biniodide  lo- 
tion, dried,  and  wiped  over  freely  with  a  solution  of  spirit  (70  per 
cent.)  and  biniodide  of  mercury  (i  in  1000).  This  is  then  dried 
away,  and  Harrington's  solution  is  applied  and  is  allowed  to  re- 
main for  two  minutes,  when  it  is  wiped  off  with  a  swab  wet  in 
spirit  solution.  No  preparation  will  sterilise  a  skin  so  effectual^ 
as  Harrington's  solution,  whose  composition  is  as  follows: 

Commercial  alcohol 640  c.c. 

Hydrochloric  acid,  pure 60  c.c. 

Perchloride  of  mercury 8  gramme 

Water 300  c.c. 

The  skin  though  thoroughly  prepared  is  always  covered  as 
soon  as  an  incision  is  made.  This  I  do  with  "  tetra  "  cloths  held  to 
the  wound  edge  by  the  special  forceps  I  designed  for  the  purpose, 
which  are  depicted  in  Fig.  5. 

It  is  supremely  important  that  the  skin  should  not 
be  roughened  or  chapped  and  that  no  irritative  rash  should 
be  caused.  Overpreparation  to  the  extent  of  damaging 
the  skin  is  almost  as  bad  as  no  preparation  at  all.  If 
there   are   any   small   furuncles    or   septic   cracks   on   the   skin 


40  ABDOMINAL    OPERATIONS. 

within  the  operation  area,  these  must  be  carefully  disinfected. 
The  only  satisfactory  method  of  doing  so  is  by  means  of  the 
actual  cautery,  the  point  of  the  hot  metal  being  kept  in  con- 
tact with  the  infected  spot  until  all  the  septic  matter  is  des- 
troyed. When  it  is  realised  that  the  yellow  spot  in  a  furuncle 
may  contain  a  pure  culture  of  the  Staphylococcus  pyogenes  au- 
reus, the  complete  annihilation  of  such  a  colony  is  seen  to  be  a 
desirable  thing. 

If  the  skin  of  the  patient  should  be  very  rough,  scaly, 
chapped,  or  cracked,  its  adequate  preparation  is  almost  impossi- 
ble.    In    these   conditions,    the   "rubber   dam"    introduced  bv 


Fig.  5. — Tetra  cloths  held  in  position  by  special  forceps. 

Dr.  J.  B.  Murphy,  of  Chicago,  will  be  found  of  the  greatest  ser- 
vice. It  consists  of  a  strong,  very  adhesive  material  which  is 
stretched  and  then  placed  on  the  abdominal  wall,  to  which  it 
clings  most  closely,  becoming,  in  fact,  for  the  time,  an  insepa- 
rable part  of  this  wall. 

Through  it  the  incision  is  made,  and  the  hand  lying 
outside,  or  any  viscus  escaping  from  the  abdomen,  lies, 
not  upon  the  abdominal  wall,  but  upon  this  sterile  rubber 
dam. 

As  a  general  rule,  no  more  preparations  than  those  in- 
dicated   are    necessary,    but    in    some    few    the    general    con- 


OPERATION.  41 

dition  of  the  patient  may  be  so  enfeebled  that  special 
precautions  are  needed.  It  is  a  matter  of  the  highest 
importance  in  all  cases  to  ensure  that  the  heart  and  the 
kidneys  are  acting  well.  Inefficient  kidneys  are  among 
the  most  serious  obstacles  to  success  in  any  major  opera- 
tions, but  especially  in  any  abdominal  operations.  A  routine 
and  most  exact  examination  of  the  urine  for  two  or  three 
days  is  therefore  necessary.  If  the  patient  be  feeble,  or 
the  heart  so  weak  as  to  be  a  cause  of  anxiety,  much  good 
may  be  done  by  hypodermic  injections  of  strychnine  and 
digitaline  for  a  few  days  before  the  operation.  Five  minims 
of  the  liquor  strychninae  may  be  given  three  or  four  times 
daily.  If  the  patient  has  been  accustomed  to  alcohol, 
his  usual  quantity  may  be  allowed  him.  All  patients  who 
are  submitted  to  any  abdominal  operations  are  clothed 
in  a  suit  of  gamgee  pajamas  made  for  them  by  the  nurse. 
After  being  made,  of  appropriate  size,  the  suit  is  well 
warmed  and  is  put  on  a  few  hours  before  the  beginning 
of  the  operation.  It  is  worn  until  all  risk  from  the  opera- 
tion is  past,  and  is  then  removed  limb  by  limb.  It  is 
most  important  that  all  patients  should  be  warmly  clad 
in  this  way  before,  during,  and  after  the  operation, 

OPERATION. 

The  operation,  if  possible,  should  be  performed  in  a 
room  specially  furnished  for  the  purpose.  In  a  public 
hospital  a  well-equipped  operation  theatre  is  always  pro- 
vided. In  a  nursing  home  or  in  a  private  house  it  is 
sometimes  necessary  to  operate  in  the  patient's  bedroom. 
The  advantage  of  this  is  that  it  is  less  of  an  ordeal  to 
the  patient,  who  is  sometimes  alarmed  at  the  prospect 
of  being  taken  to  a  special  room,  and  that  there  is  less 
of  lifting  or  of  carrying  after  the  operation.  These  trivial 
advantages  are,  however,  greatly  outweighed  by  the  disad- 
vantages, which    are,  that    in    the    conversion    of    a    bedroom 


42 


ABDOMINAL   OPERATIONS. 


into  a  theatre  there  is  much  traffic,  many  tables,  instru- 
ments, etc.,  having  to  be  taken  into  the  room;  that  it  is 
not  possible  to  have  all  the  needed  appliances  to  hand 
with  the  same  certainty,  and  that,  finally,  the  smell  of  the 
anaesthetic  clings  to  the  room  for  many  hours.  An  ordi- 
nary room  in  a  nursing  home  can  readily  be  converted 
into,  and  equipped  as,  an  operation  room  to  the  great  con- 
venience  of    the   surgeon.       Such   a   room   should    be   cleaned 


Fig.  6. — Crile's  method  of  anoci-association.     The  skin  (not  the  subcutaneous 
tissue)  is  injected  with  a  solution  of  novocaine  i :  400. 


thoroughly  and  disinfected  by  formalin  vapour  at  frequent 
intervals,  and  always  after  any  septic  operation.  The  op- 
eration table  should  have  the  foot  towards  the  light, 
and  should  be  of  good  height.  ^lany  of  the  tables  are 
about  three  inches  too  low.  If  the  table  is  high,  it  is 
more  convenient  and  more  comfortable  for  the  surgeon, 
and    if,    for    any    brief    manipulation,    it   is   necessary  for   the 


OPERATION. 


43 


surgeon    to    be    at    a    rather    high    level,  a    plain    metal     or 
wooden  footstool  can  be  used. 

The  preparations  for  the  operation  must  all  be  com- 
pleted before  the  anaesthetic  is  administered,  so  as  to  ensure 
that  the  patient  is  not  kept  under  any  longer  than  is  absolutely 
necessary.  The  choice  of  the  anaesthetic  is  no  longer  left  to  the 
administrator  thereof,  but  the  procedure  which  Crile  has  advo- 
cated for  the  production  of  the  shockless  operation  by  anoci- 


r 


Fig.  7. — The  anterior  sheath  of  the  rectus  muscle  is  infiltrated  with  novocaine. 


association  is  the  one  I  now  adopt.  The  investigations  of  Crile 
have  shown  that  while  inhalation  anesthesia  prevents  the  feeling 
of  pain,  it  does  not  prevent  the  nerve  impulses  set  up  by  a  sur- 
gical operation  from  reaching  the  brain.  These  impidses  cause 
exhaustion  of  the  brain  cells,  and  result  in  shock  of  a  lesser  or 
greater  degree  of  severity. 

On  the  other  hand,  local  anfesthesia,  although  it  may  block 
the  nerve  impulses  originated  by  the  surgeon's  manipulations, 


44 


ABDOMINAL   OPERATIONS. 


cannot  prevent  the  destructive  psychic  strain  from  which  patients 
operated  upon  under  a  local  anaesthetic  must  suffer.  In  order 
therefore  to  obtain  true  anoci-association  both  a  local  and  a 
general  ansesthetic  must  be  employed. 

The  anaesthetic  technique  for  abdominal  operations  consists 
of  a  preliminary  injection  of  one-sixth  of  a  grain  of  morphine  and 
one-hundredth  of  a  grain  of  scopolamine  and  one  one-hundred- 
and-twentieth  of  a  grain  of  atropine  about  half  an  hour  before 


Fig.  8. — The  peritoneum  is  opened,  the  edges  seized  with  long  clips,  and 
everted.  A  solution  of  quinine  and  urea  hydrochloride  (i  in  150  or  200)  is 
injected  from  within. 

the  actual  commencement  of  the  operation.  This  quiets  the  pa- 
tient and  prevents  excessive  anxiety.  Inhalation  anaesthesia  is 
induced  in  the  ordinary  way  with  nitrous  oxide  gas  followed  by 
ether.  As  soon  as  the  patient  is  unconscious  and  the  transverse 
scratching  of  the  skin  made,  to  which  I  shall  refer  later,  the 
hne  of  incision  is  infiltrated  with  I  in  500  solution  of  novocaine, 
taking  care  to  make  the  injection  into  the  skin  itself,  and  not 


OPERATION, 


45 


beneath  it.  The  accurate  attainment  of  this  intradermal  in- 
jection is  signified  by  a  white  "pig  skin"  appearance  along  the 
injection  line. 

Incision  through  this  anaesthetised  area  exposes  the  rectus 
sheath,  which  is  in  turn  injected  somewhat  widely,  submitted 
to  pressure  to  diffuse  the  solution,  and  then  incised.  The  rec- 
tus muscle  next  receives  a  few  injections.  The  peritoneum  is 
now   anaesthetised   by   passing   the   needle   between   the   trans- 


Fig.   9. — The  infiltration  uf   the   jieritoneum  is  carried   throughout  the  suture 
length  of  the  incision  and  to  a  distance  of  lA  in.  from  the  cut  edge. 


versalis  fascia  and  the  peritoneum  itself.  A  pause  is  made  while 
all  bleeding  points  are  ligatured.  This  pause  should  be  sufficient 
to  ensure  complete  blockage  with  the  novocaine.  The  peri- 
toneum is  now  raised  gently  with  forceps  and  incised  for  about 
i".  The  incised  area  is  now  infiltrated  on  the  abdominal  aspect 
and  the  incision  then  prolonged;  the  peritoneum  being  raised 
gently  with  forceps  and  each  newly  incised  portion  reinfiltrated 
over  an  area  reaching  2"  bevond  the  wound  edge  in  everv  direc- 


46 


ABDOMINAL   OPER.\TIONS. 


tion.  The  solution  used  for  this  peritoneal  injection  is  a  ^/i  per 
cent,  solution  of  quinine  and  urea  hydrochloride.  If  the  injection 
has  been  successful  a  blister  will  be  raised  on  the  peritoneum  at  the 
site  of  each  puncture.  Pressure  with  the  finger  on  these  blisters 
ensures  adequate  absorption  of  the  anesthetic.  If  the  blocking 
has  been  complete  it  will  be  found  that  with  a  very  light  degree 
of  ether  anaesthesia  there  is  no  rise  of  intra-abdominal  pressure, 
no  tendency  to  expulsion  of  the  intestines  and  no  muscular 
rigidity.  Before  closing  the  abdomen  the  injections  of  quinine 
and  urea  into  the  peritoneum  are  repeated. 


Fig.  lo. — The  skin  is  closed  by  deep  sutures  -o'hich  take  all  the  layers  of  the 
abdominal  wall,  except  the  peritoneum,  which  is  closed  by  a  continuous  catgut 
suture. 


The  punctures  made  b}^  the  skin  tension  sutures  should  be 
injected  with  novocaine. 

If  malignant  disease  and  acute  infective  conditions  are  ex- 
cluded infiltration  of  the  meso-appendix,  of  the  base  of  the  gall- 
bladder, of  the  uterus  and  the  broad  ligaments,  the  round  liga- 
ments, mesentery,  or  any  portion  of  parietal  peritoneum  can 
be  carried  out.  Novocaine  is  used  for  all  the  extraperitoneal 
injections;  quinine  and  urea  for  the  intraperitoneal.  As  much 
as  6  ounces  of  quinine  and  urea  (/^  to  3<^  per  cent.)  may  be 
used  without  danger. 


OPERATION. 


47 


The  anaesthesia  produced  in  this  way  lasts  for  about  five  days, 
especially  if  the  quinine  and  urea  injections  into  the  peritoneum 
are  repeated  before  closing  the  abdomen.  In  addition  to  mini- 
mising, or  possibly  entirely  preventing,  post-operative  shock, 
it  also  lessens  pain  and  necessitates  the  administration  of  a 
smaller  quantity  of  inhalation  ansesthetic.  The  post-operative 
rise  of  temperature  with  acceleration  of  the  pulse  and  also  the 


Fig.  II. — The  stitch  punctures  are  injected  with  a  solution  of  quinine  and 

urea  hydrochloride. 


abdominal  distension  and  nausea,  are  very  considerably  mini- 
mised. 

A  slight  objection  to  this  procedure  is  the  tissue  oedema  which 
lasts  for  some  time  even  after  the  healing  of  the  wound. 

A  competent  assistant;  a  nurse  to  look  after  instruments, 
ligatures,  etc.  (this  can  be  done  by  the  surgeon  himself 
if  he  so  wishes) ;  and  a  nurse  who  is  to  change  bowls  of 
saline    solution,  and    generally    fetch    and    carry,  are    all    the 


48 


ABDOMINAL   OPERATIONS. 


staff  necessary  for  any  operation.  The  nurse  who  carries 
basins,  etc.,  should  be  told  to  keep  her  hands  away  from 
contact  with  anything  which  is  afterwards  to  be  handled 
by  the  operator  or  assistants.  Her  hands,  for  example,  should 
be  outside  a  basin  she  is  carrying;  the  thumbs  should  not  be, 
as  they  often  are,  inside  the  edges  of    any  vessel. 

The     abdominal     incision     is     made     in     accordance     with 
the  principles  mentioned  elsewhere.     Before  beginning  the  ab- 


Fig.    12. — The  right  way  and  the  wrong  way  to  carry  a  basin. 

dominal  incision  a  few  light  transverse  scratches  are  made  with 
a  needle,  at  distances  of  about  one  inch.  The  object  of  this  is  to 
afford  a  guide  for  the  introduction  of  the  deep  stitches  at  the 
completion  of  the  operation.  Each  scratch  on  one  side  exactly 
meets  its  fellow  on  the  other,  and  a  mathematical  accuracy  of 
apposition  results.  The  great  majority  of  the  infections  during 
the  conduct  of  an  operation  come  from  the  patient's  skin.  No 
method  of  skin  preparation  yet  devised  will  ensure  that  the  skin 
remains  sterile  for  more  than,  say,  half  an  hour.     At  the  end  of 


OPERATION.  49 

that  time,  indeed  as  a  rule  long  before,  organisms  have  been 
sweated  up  from  the  depths  of  the  skin,  and  are  ready  to  cause 
infection.  The  skin,  therefore,  even  after  thorough  preparation, 
is  kept  entirely  out  of  the  operation  field.  This  is  best  done  by 
applying  tetra  cloths  over  the  edges  of  the  wound  and  fixing  them 
there  by  means  of  the  special  forceps  which  I  introduced  for 
this  purpose  several  years  ago.  By  this  means  no  hand  nor  any 
viscus  need  come  into  contact  with  uncovered  skin  from  the  be- 
ginning of  the  operation  to  the  end.  When  the  tetra  cloths  are 
removed  upon  the  closure  of  the  first  layer  of  the  wound  a  swab 
wet  with  spirit  and  biniodide  lotion  is  used  vigorously  to  wipe 
each  side  of  the  incision  before  any  deep  sutures  are  passed. 

As  soon  as  the  abdomen  is  opened,  a  complete,  or  at 
least  an  adequate,  examination  of  all  the  parts  concerned 
must  be  made.  It  is  so  easy  to  omit  noticing  points 
which  are  vital  to  the  success  of  an  operation.  For  exam- 
ple, an  hour-glass  stornach  may  well  be  overlooked;  many 
such  cases  are  recorded,  owing  to  the  fact  that  a  dilated 
pyloric  pouch  has  been  mistaken  for  the  whole  organ.  A 
single  stricture  of  the  intestine  has  been  operated  upon, 
when  multiple  strictures  were  present;  and  so  with  wounds 
of  the  intestine, — one  has  been  sutured,  another  left  undis- 
covered. The  appendix  has  been  removed  and  a  growth 
in  the  intestine  left  unrecognized.  A  gall-stone  has  been 
removed  from  the  gall-bladder,  and  another  left  in  the 
common  duct.  And  so  the  list  might  be  increased.  A 
few  minutes  spent  in  painstaking  examination  of  all  the 
parts  affected,  or  likely  so  to  be,  is  well  repaid  in  better 
results. 

The  lesion  having  been  disclosed,  the  area  to  be  operated 
upon  is  isolated.  This  should  be  done  in  a  routine  manner. 
In  "packing  off"  the  abdominal  cavity  from  the  parts 
immediately  concerned,  I  use  sterile  gauze  swabs  of  large  size, 
well  packed  into  position,  so  as  to  completely  surround  the  field 
of  operation.     They  remain  unchanged  throughout  the  operation. 


50  ABDOMINAL   OPERATIONS. 

Each  swab  has  a  long  gauze  tape  upon  it,  and  to  each  tape  a  clip 
is  fastened.  On  the  inner  side  of  this  outer  barrier  of  large 
swabs  as  many  mackintosh  cloths  are  placed,  as  are  necessary 
completely  to  isolate  the  area  of  manipulation,  both  from  the 
outer  layer  of  large  fiat  swabs,  and  from  the  wound  edges ;  these 
are  changed  as  soon  as  soiled.  This  method  of  having  a  double 
protection  is,  I  feel  sure,  the  most  satisfactory  of  all,  and  is  the 
most  efficient  in  preventing  any  soiling  of  the  parts.  It  is 
important,  too,  to  remember  that  the  wound  edges  require  pro- 
tection just  as  much  as  the  general  peritoneal  cavity  and  the 
viscera.  The  pus  from  an  infected  gall-bladder,  or  the  f^cal 
matter  from  the  intestine,  if  brought  into  even  the  slightest 
contact  with  the  abdominal  wall  will  result  in  a  suppuration  of  the 
wound,  and  not  improbably  in  a  weakened  scar  and  a  ventral 
hernia.  The  swabs  must  therefore  be  made  to  ensure  protec- 
tion for  the  wound  edges,  or  better  still,  the  mackintosh  cloths 
which  I  have  mentioned  may  be  carefully  folded  over  all  wound 
edges  so  that  all  parts  of  them  are  invisible.  The  most  dainty 
care  should  be  exercised  all  the  time.  A  very  effective  method 
of  preventing  soiling  in  septic  cases  is  to  smear  the  fascial  and 
muscular  layers  of  the  abdominal  wall  with  hot  sterile  vaseline 
containing  i  per  cent,  of  formalin.  This  forms  an  efficient  coat- 
ing for  the  tissues,  preventing  the  penetration  of  septic  material 
and  lessening  the  area  of  subsequent  suppuration. 

The  swabs  when  introduced  must  be  wrung  out  of  hot 
sterile   salt   solution  (temperature   about    io5°-iio°F.). 

Instruments  when  boiled  may  be  kept  in  a  flat  dish 
containing  hot  weak  carbolic  lotion,  or  may  be  spread  out 
upon  a  dry  sterilised  towel;  preferably  the  latter,  for  all 
operative  work  should  be  kept  as   dry  as   possible. 

The  operation  should  be  conducted  as  speedily  as  is  con- 
sistent with  careful  and  complete  work.  An  operator  should 
always  be  speedy,  never  hasty.  Speed  should  be  the  achieve- 
ment,   not   the   aim,    of   the   operator. 


THE   TREATMENT   OF   ADHESIONS.  5I 

THE  TREATMENT  OF  ADHESIONS. 

Adhesions  are  frequently  encountered  in  all  abdominal 
operations.  They  are,  of  course,  the  result  of  inflammatory 
conditions,  sometimes  recent,  sometimes  long  past.  The  opera- 
tion may  be  called  for  by  conditions  which  are  due  directly 
and  solely  to  the  adhesions,  or  the  adhesions  may  be  a  mere 
incident  in  the  operation  which  is  primarily  directed  to  the 
removal  of  a  different  condition. 

The  question  that  arises  is  as  to  the  manner  in  Avhich  such 
adhesions  should  be  dealt  with, — are  they  to  be  separated  al- 
ways ;  may  they  be  ignored  sometimes ;  or,  after  separation, 
shall  something  be  done  to  substitute  for  one  viscus  another 
whose  adhesion  would  be  relatively  unimportant  ? 

When  adhesions  are  encountered  in  a  case  of  gastric  ulcer 
it  is  almost  always  desirable  to  separate  them.  If,  for  example, 
an  ulcer  be  attached  by  a  stalk  of  adhesion  to  the  under  surface 
of  the  liver,  the  adhesion  should  be  cut  through,  and  probably 
the  ulcer  be  removed.  Such  adhesions  to  the  liver  or  the  dia- 
phragm may  be,  and  not  seldom  are,  a  cause  of  great  distress, 
of  pains  which  radiate  to  the  chest  or  elsewhere.  A  constantly 
moving  organ  like  the  stomach  cannot  well  brook  interference. 
An  anchoring  of  its  walls  to  one  spot  is  often  the  cause  of  much 
suffering.  When  such  adhesions  are  separated,  conditions  re- 
main behind  which  may  set  up  fresh  plastic  peritonitis  and  new 
adhesions  result.  Even  if  such  new  adhesions  form,  it  is  prob- 
able that  they  will  be  less  crippling  than  the  old  ones.  But,  in 
order  to  prevent  their  formation  between  the  stomach  and  a 
fixed  point,  such  as  the  liver  or  the  diaphragm,  the  omentum 
may  be  folded  OA'er  the  bare  or  roughened  area. 

If  adhesions  around  the  gall-bladder  are  present  when  it  is 
necessary  to  perform  the  operation  of  choledochotom}',  the 
propriety  of  ignoring  or  of  dealing  with  adhesions  depends  upon 
a  variety  of  circumstances.  If  the  patient  be  old,  or  feeble, 
or  ill  suited  to  long  surgical  manipulations,  it  is  best  to  ignore  the 


52  ABDOMINAL   OPERATIONS. 

adhesions  altogether  and  to  perform  the  manoeuvre  of  "rota- 
tion of  the  common  duct"  described  elsewhere.  Adhesions 
around  the  gall-bladder  in  a  case  of  this  kind  are  often  very 
dense,  exceeding^  complex,  and  may  involve  the  colon,  which 
tears  not  tmreadity  if  roughly  handled.  The  gall-bladder  in 
such  a  case  has  undergone  sclerosis,  and  if  stones  be  within  it, 
they  are  of  no  great  consequence.  They  have  undergone,  very 
often,  what  Mr.  Rutherford  Morison  calls  "the  natural  cure" 
and  may  safety  be  left  undisturbed.  These  remarks  only  apply 
to  the  aged  and  enfeebled.  In  A^oung,  or  middle-aged  and 
healthly  people,  it  is  better  to  separate  the  adhesions,  and,  in 
addition,  to  perform  cholecystotomy  or  cholecystectomy,  as 
may  seem  best. 

With  regard  to  adhesions  around  the  appendix,  it  is  proper 
always  to  separate  them  and  to  remove  the  appendix.  With 
the  cause  removed,  adhesions,  even  if  they  re-form  here,  do  not 
come  in  such  denseness  as  before,  and  are  probably  only  tran- 
sient. I  have  certainly  seen  them  disappear  when  the^abdomen 
came  to  be  examined  later. 

Adhesions  are  often  said  to  result  from  surgical  manipula- 
tions within  the  abdomen.  If  they  do,  I  believe  they  are  due  to 
one  of  two  chief  causes, — roughness  in  manipulation  (that  is, 
traumatism)  or  sepsis.  In  cases  of  carcinoma  of  the  stomach 
when  a  preliminary^  gastro-entei'ostomy  is  performed,  the  ab- 
domen is  reopened  in  a  couple  of  weeks  for  the  purpose  of  per- 
forming partial  gastrectomy.  In  such  cases  I  have  not  seen  ad- 
hesions of  any  kind.  The  amount  of  handling  that  is  necessary 
for  most  operations  can  be  borne  by  the  peritoneum  without 
any  inflammatory  response. 

Dr.  E.  Wyllys  Andrews  has  introduced  an  operation  which 
he  describes  as  " colohepatopexy  or  colon  substitution."  He 
considers  that  adhesions  around  the  gall-bladder  are  unavoid- 
able after  operations  thereon,  and  points  out  that  such  adhe- 
sions are  only  serious  when  they  involve  the  stomach  or  the 


THE   TREATMENT   OF    ADHESIONS.  53 

beginning   of  the   duodenum.     When   the   colon   is   implicated, 
there  are  no  symptoms.     His  technique  is : 

1.  A  free  incision,  avoiding  old  scar. 

2.  Careful  inspection  of  the  position  and  the  mobility 

of  the   stomach  and  separation  of  adhesions. 

3.  The  transverse  colon  and  the  omentum  are  pulled  up 

and  thrust  into  the  space  between  the  pylorus 
and  the  liver.  This  new  relation  is  maintained 
by  suturing  the  colon  and  omentum  to  the  gastro- 
hepatic  ligament. 

He  draws  the  following  conclusions: 

1.  Gall-tract  adhesions  are  inevitable  after  disease  and 

operations. 

2.  They  are  beneficent,   harmless,  and  symptomless  in 

all  but  a  few  cases. 

3.  These  few  represent  malposition  rather  than  trouble 

from  adhesions,  per  se. 

4.  The  colon,  gall-bladder,  duodenum  and  pylorus  can 

adhere  to  each  other  without  impairing  their  func- 
tion. The  other  parts  of  the  stomach  cause  trouble 
if  involved. 

5.  Such  adhesions  will  re-form  when  separated  unless 

the  colon  is  substituted  for  the  stomach. 

6.  The  causing  of  colon  adhesions  to  the  liver  does  not 

distiirb  the  function  perceptibly. 

7.  Certain  vague  gastric  disturbances  have  probably  been 

treated  by  gastro-enterostomy  when  the  patients 
would  have  had  more  benefit  from  this  operation. 

I  have  long  held  the  view  that  the  falciform  ligament  offered 
great  help  to  the  surgeon  in  these  cases.  It  can  be  attached  to  the 
omentum  close  to  the  hepatic  flexure  in  such  manner  as  to  form 
a  veil  or  curtain  separating  the  gall-bladder  or  its  fossa,  when 
cholecystectomy  has  been  done,  from  the  duodenum  or  stomach, 
and  so  preventing  the  formation  of  crippling  adhesions. 

When  adhesions  are  encountered  they  should  be  separated 


54  ABDOMINAL  OPERATIONS. 

with  great  gentleness.  This  is  best  done  by  "wiping"  them 
awav  with  a  piece  of  sterile  gauze.  Traction  should  always 
be  avoided  as  much  as  possible,  for  it  is  productive  of  muscular 
spasm  dining  the  operation  and  of  shock  subsequently.  Shock 
is  ver\'  often  the  response  on  the  patient's  part  to  manipulations 
which  would  have  been  recognised  as  productive  of  severe  pain 
if  the  operation  had  been  performed  without  an  ansesthetic. 

If  the  omentum  has  been  separated  and  a  rough  edge  or  a 
ligatiu-ed  stump  remains,  this  may  be  rolled  in  upon  the  omentum 
itself  which  is  closed  over  by  a  stitch.  This  ensures  that  onl}^ 
smooth  surfaces  present  on  the  outside. 

DRAINAGE  AFTER  ABDOMINAL  OPERATIONS. 
The  use  of  drainage  in  abdominal  surger}'  has  been  frequently 
and  fully  discussed,  and  has  attracted  the  attention  of  many 
laborator}-  workers.  Opinion  as  to  its  worth  has  veered  from 
one  direction  to  another,  almost  at  the  caprice  of  fashion.  At 
one  time  it  was  customan^  to  drain  after  many  of  the  simplest 
operations,  if  a  few  adhesions  had  been  separated,  or  CA^en  the 
slightest  damage  inflicted  upon  the  peritoneum.  Lawson  Tait, 
whose  emphatic  pronouncements  rightly  carried  great  weight, 
wrote,  ''When  in  doubt,  drain."  Doubt,  in  those  early  days, 
was  the  prevailing  mental  attitude  and  the  result  was,  for  a 
time,  the  almost  constant  employment  of  a  tube.  When  a  case 
"went  wrong"  if  no  drain  had  been  introduced,  the  act  of 
omission  was  held  responsible  for  the  disaster.  The  principles 
which  underlie  the  use  of  drainage  are  now  better  understood, 
with  the  result  that  drainage  of  the  abdomen  has  very  largely 
fallen  into  disuse.  When  a  drain  is  introduced  into  the  abdomen, 
whether  gauze  or  a  tube  be  used,  certain  results  are  con- 
stantly obser^'ed.  There  is,  for  twelve  to  twenty-four  hours,  a 
fairly  profuse  discharge  of  a  serous,  perhaps  slightly  turbid,  or 
blood-stained  fluid.  After  this  time,  the  quantity  gradually 
lessens  and  the  drain  is  then  generally  removed.  If  the  drain, 
however,  be  kept  in,  suppuration  follows,  the  result  of  an  in- 


DRAINAGE   AFTER  ABDOMINAL   OPERATIONS.  55 

evitable  infection.  Since  a  general  infection  of  the  peritoneal 
cavity  does  not  occur,  it  is  clear  that  the  pus  comes  only  from 
the  lining  membrane  of  the  track.  It  has  been  shewn  by  ex- 
perimental work  that  the  drainage  material,  whatever  its  nature, 
acts  as  an  irritant.  It  is  at  once  surrounded  by  the  intestines 
and  omentum  from  which  a  serous  exudate  occurs,  and  a  local 
h3^per£emia  is  observed.  Yates  describes  the  changes  thus: 
"As  the  inflammatory  reaction  increases  a  fibrinous  exudate  is 
formed  and  there  is  more  intense  local  congestion  and  some 
oedema.  The  serosa  loses  its  lustre  and  is  finally  covered  with 
opaque  plastic  fibrin.  This  fibrinous  surface  persists  in  the 
presence  of  smooth  drains  for  at  least  seven  days.  Gauze,  how- 
ever, acts  differently.  The  fibrin  becomes  incorporated  in  its 
meshes,  followed  by  an  ingrowth  of  granular  tissue,  so  that,  when 
the  gauze  is  removed,  instead  of  leaving  a  smooth,  yellowish 
surface,  it  is  rough  and  bleeding,  with  fibrin  and  superficial  tags 
of  granulation  tissue  still  clinging  to  the  more  superficial  portion 
of  the  gauze. " 

If  the  track  left  be  examined  after  a  gauze  drain  has  been 
removed,  some  fine  filaments  of  the  cotton  fibre  are  found. 
Infection  of  the  canal  filled  by  the  drain  is  unfailing;  it  may  be 
due  to  organisms  escaping  from  the  intestine,  or  to  others  which 
travel  downwards  from  the  skin.  The  organism  most  con- 
stantly found  is  the  staphylococcus  albus.  Clark  found,  at 
autopsy,  that  infected  pockets  occasionally  were  found  close 
to  the  drain  track,  and  also  that  the  organisms  causing  the 
peritonitis  might  persist  in  the  drain  track  after  the}^  had  dis- 
appeared from  the  general  peritoneal  cavity. 

If,  in  dogs,  a  drain  be  introduced  into  the  general  peritoneal 
cavity  and  in  eighteen  or  twenty-four  hours  a  coloured  solution 
be  injected  through  a  needle  passed  into  the  peritoneum  just 
below  the  ensiform  cartilage,  none  of  the  fluid  passes  out  at  the 
site  of  the  drain,  even  when  the  general  cavity  is  filled  to  its 
utmost  capacity.  A  tube,  it  is  clear,  does  not  drain  the  general 
peritoneal   cavity   at   all   after   this   lapse    of   time.     If   during 


56  ABDOMINAL   OPERATIONS. 

an  operation  for,  say,  general  peritonitis  due  to  appendicitis, 
tubes  be  placed  in  both  the  iliac  fossse,  and  another  through  a 
median  incision  into  the  pouch  of  Douglas,  a  stream  of  salt  so- 
lution introduced  into  the  general  peritoneum  will  flow  from 
all  the  openings.  Temporary  drainage  of  the  peritoneum  is 
therefore  clearly  possible.  Experience  shews,  however,  that 
all  drain  materials  are  speedly  isolated  and  cease  then  to  do 
more  than  drain  the  cavity  which  they  themselves  have  produced. 
Prolonged  drainage  of  the  general  peritoneal  cavity  is  a  physical 
impossibility.  The.  tube  or  wick  of  gauze  is  almost  immedi- 
ately isolated  and  it  is  not  long  before  it  is  encapsulated.  It 
provokes  a  copious  thin  discharge  from  the  serous  surfaces  which 
surround  it,  forming,  as  Yates  terms  it,  "a  potential  cavity 
which  is  speedily  converted  into  an  actual  cavity ' '  by  the  action 
of  a  plastic  fibrinous  exudate,  forming  encapsulating  adhesions. 
Yates,  after  a  very  comprehensive  discussion  of  the  whole 
question,  comes  to  the  following  conclusions : 

Drainage  of  the  general  peritoneal  cavity  is  physically  and 
physiologically  impossible. 

The  relative  encapsulation  of  the  drain  is  immediate. 

The  absolute  encapsulation  occurs  early  (less  than  six  hours 
in  dogs)   and  can  be  retarded  but   not   prevented. 

The  serous  external  discharge  is  an  exudate  due  to  the 
irritation  of  contiguous  peritoneum  by  the  drain. 

There  is  a  similar  inward  current  from  the  potential  into  the 
general  cavity. 

This  external  exudate  diminishes  remarkably  with  the 
formation  of  encapsulating  adhesions. 

These  adhesions,  under  approximately  normal  conditions, 
form  about  any  foreign  body. 

Their  extent  and  density  depend  on  the  degree  and  the 
duration  of  the  irritation  of  this  body. 

Primarily  fibrinous,  these  adhesions  become  organised  in  a 
few  days  (three  days  in  dogs). 

If  the  irritation  persists,  they  become  progressively  more 
mature  fibrous  tissue. 

After  irritation  ceases,  their   disappearance  depends  princi- 


AFTER-TREATMENT.  57 

pally  upon  a  mechanical  factor, — the  ability  of  the  involved 
surfaces  to  pull  themselves  or  to  be  pulled  loose. 

Drains  should  be  the  least  irritating,  and  should  be  gradually 
and  finally  removed  as  soon  as  possible. 

Irrigation  through  drains  is  futile  to  prevent  adhesions,  and 
dangerous. 

After  a  drain  is  inserted,  all  intra-abdominal  movements 
should  be  reduced  to  a  minimum. 

As  soon  as  the  drain  is  removed,  intra-abdominal  activity 
should  be  stimulated,  to  aid  in  the  disappearance  of  the  re- 
maining adhesions. 

Peritonitis,  if  not  too  severe,  possibly  aids  in  the  rapidity  of 
the  encapsulation  of  the  drain. 

A  drain  in  the  presence  of  infection  is  deleterious  to  peritoneal 
resistance,  and  should  only  be  introduced  to  exclude  more 
malign  influences. 

Postural  methods,  unless  destined  to  facilitate  encapsulation, 
are  both  futile  and  harmful,  as  far  as  drainage  is  concerned. 

Peritoneal  drainage  must  be  local,  and  unless  there  is  some- 
thing to  be  gained  by  rendering  an  area  extraperitoneal,  or  by 
making  from  such  an  area  a  safe  path  of  least  resistance  leading 
outside  the  body,  there  is,  aside  from  hemostasis,  no  justification 
for  its  use. 

It  is  therefore  clear  that  the  use  of  gauze  or  rubber  protective, 
or  tubes  of  an}^  sort  left  in  the  abdominal  wound,  should  be 
restricted  to  those  cases  where  it  is  necessary  to  exercise  pressure 
to  arrest  bleeding ;  or  to  isolate  a  part  of  the  peritoneum  when  a 
known  infection  has  occurred;  or  when  the  escape  of  a  fluid 
along  a  track  isolated  from,  the  peritoneum  is  anticipated  (as 
in  choledochotomy) ;  or  for  temporary  drainage  of  the  general 
peritoneal  cavity.  The  length  of  time  during  which  drainage 
of  the  general  peritoneum  is  possible  has  not  been  accurately 
reckoned,  but  it  is  almost  certainly  very  brief,  probably  not 
more  than  twelve  hours  as  a  maximum. 

AFTER-TREATMENT. 

No  small  part  of  the  success  of  all  abdominal  operations 
depends  upon  the  after-treatment. 


58 


ABDOMINAL   OPERATIONS. 


As  soon  as  the  patient  is  returned  to  bed  he  is  ahowed 
to  lie  quite  fiat  or  witli  one  small  pillow  for  an  hour  or 
two,  until  the  effect  of  the  anaesthetic  is  passing  away. 
Then  two  or  three  or  more  pillows  are  given  and  the  patient 
is  propped  up  with  them.  After  all  operations  upon  the 
stomach  and  after  some  upon  the  gall-bladder,  the  patients 
are  almost  in  a  sitting  position.  This  is  generally  far 
more     comfortable     for     them,  and     does     much     to     prevent 


.\ 


Fig.  13. — Position  of  a  patient  in  bed  immediately  after  the  performance  of 
gastro-enterostoni5\  As  soon  as  the  patient  conies  round  from  the  anaesthetic 
he  is  propped  up  in  this  way. 

the    backache    which    many    patients    after    abdominal    opera- 
tions complain  of  as  their  chief  trouble. 

Thirst  is  sometimes  distressing  within  the  first  twenty- 
four  hours ;  it  is  relieved  by  allowing  the  patient  to  flush 
the  mouth  out  frequently  with  water,  soda  water,  or  Giess- 
hiibler  water.  Nothing  is  given  to  drink  until  the  feeling 
of  sickness  due  to  the  anaesthetic  is  over,  but  after  that 
there    is     no    restriction    as     to     quantity.      A    few    sips    of 


AFTER-TREATMENT.  59 

water  are  given  at  first,  tentativel}" ;  if  these  are  retained 
and  there  is  no  nausea,  the  quantity  is  rapidly  increased, 
and  after  twenty-four  to  forty-eight  hours  a  couple  of 
pints  of  fluid  may  be  given  during  the  daytime.  I  do 
not  think  there  is  need  to  stint  the  patient  in  the  matter 
of  fluids,  as  was  at  one  time  the  universal  practice.  It 
seems  to  me  not  improbable  that  death  took  place  in  some 
of  the  cases  I  saw^  in  my  earliest  experience,  literally  from 
starvation.  There  is  no  harm  done,  so  far  as  I  have  been  able 
to  determine,  by  allowing  the  patient  to  drink  freely,  provided 
the  risks  of  vomiting  are  over.  The  need  for  fluid  is  greater  in 
patients  who  are  weak  and  in  much  enfeebled  health.  In  old 
patients,  especially  in  malignant  cases,  I  have  often  given  a  cup 
of  tea,  or  some  other  favourite  drink,  to  the  patient  within  three 
or  four  hours  of  the  completion  of  the  operation  of  gastro- 
enterostomy, or  partial  gastrectomy,  and  nothing  but  good  has 
resulted. 

After  the  first  twenty-four  hours,  milk,  soups,  and  a 
little  jelly  or  pudding  may  be  given.  The  giving  of  solid 
food  I  generally  delay  for  five  to  ten  days,  according  to 
the  condition  of  the  patient  and  the  nature  of  the  opera- 
tion. A  few  grapes  or  the  juice  of  an  orange  may  be 
given  from  the  first,  and,  as  a  rule,  are  much  appreciated. 
In  the  choice  of  fluid  food  during  the  first  few  days  I 
leave  much  to  the  patient,  giving  her  or  him  those  things 
which   by   earlier   questioning  we   have   found   to   be   liked. 

If  fluid  food  is  withheld,  as  was  formerly  the  custom, 
the  amount  of  urine  excreted  is  often  ver}^  small.  In  a 
long  series  of  cases  operated  upon  in  the  Leeds  Infirmary 
during  the  time  I  was  a  resident  officer,  I  found  that 
between  ten  and  twelve  ounces  was  the  average  amount 
passed  in  the  first  twenty-four  hours.  The  excretion  of 
urine  is  always  diminished  after  an}^  abdominal  operation, 
but  over  a  pint  should  be  passed  in  the  first  twenty-four 
hours. 


6o  ABDOMINAL   OPERATIONS. 

I  do  not  allow  the  catheter  to  be  passed,  as  a  rule. 
If  there  is  difficulty  in  voiding  urine  a  hot  fomentation 
will  generallv  be  helpful.  If  no  urine  is  passed  at  the  end 
of  twenty-four  hours  or  if  the  patient  is  uncomfortable, 
the  catheter  is  passed,  with  all  the  usual  precautions.  Some 
patients  are  found  to  pass  a  small  quantity  of  urine, 
three  or  four  ounces,  frequentl}^  It  will  generally  be 
found  that  they  have  an  overdistended  bladder,  and  cathe- 
terism  will  then  be  necessary. 

An  exact  record  should  be  kept  of  the  amount  of  urine 
passed  until  all  danger  from  the  operation  is  over. 

Rectal  injections  of  saline  solution  are  given  almost 
invariably  for  twenty-four  or  forty-eight  hours,  until,  that 
is  to  say,  the  patient  is  getting  a  fair  quantit}^  of  fluid 
b}^  the  mouth.  I  do  not  give  an}^  form  of  nutrient  enema. 
Salt  and  water,  one  teaspoonful  to  a  pint,  with  or  without 
brandy,  forms  the  usual  enema.  In  quantit}^  I  give  ten  ounces 
or  more  as  seems  desirable,  every  three  or  four  hours.  Glucose 
may  occasionally  be  given  in  the  enema.  It  is  water  that  is 
needed  by  the  patient,  and  anything  else  given  in  a  so-called 
nutrient  enema  is  of  no  value. 

Among  the  most  important  recent  additions  to  the  after- 
treatment  of  patients  submitted  to  abdominal  operations  of  any 
kind,  the  method  of  proctoclysis  introduced  by  J.  B.  Alurphy 
is  undoubtedly  the  chief.  The  abundant  supply  of  fluid  by  the 
rectum  alters  the  whole  aspect  of  a  difficult  and  dangerous  case; 
the  appearance  of  the  patient  is  greatly  improved:  the  lips  are 
red  and  the  eyes  clear;  the  skin  acts  freely;  thirst  is  lessened  or 
abolished  and  the  pulse  keeps  full  and  slow.  The  amount  of 
fluid  which  can  be  absorbed  in  this  way  is  very  remarkable.  I 
have  on  many  occasions  administered  15  pints  or  more  within 
twenty-four  hours.  Probably  this  is  more  than  is  necessary  or  de- 
sirable; 10  or  12  pints  should  be  all  that  is  needed.  If  a  large 
quantity  is  absorbed  the  face  and  hands  may  become  oedematous. 
The  strain  thrown  upon  the  kidneys,  especially  if  they  are  not  fully 


AFTER-TREATMENT.  6l 

competent,  by  the  administration  of  so  much  water  and  so  large 
a  dose  of  salt,  may  be  a  factor  not  always  to  be  ignored;  never- 
theless in  my  own  experience  nothing  but  good  has  resulted  from 
this  lavish  administration  of  fluids.  It  is  possible  that  the  colon 
ceases  to  absorb  when  the  needs  of  the  body  are  satisfied. 

The  mode  of  administration  best  adapted  for  the  purpose  is 
that  originally  introduced  by  Murphy:  there  have  been  several 
subsequent  modifications  by  other  surgeons,  but  no  improve- 
ments. The  cannula  which  lies  in  the  rectum  should  reach  a 
little  above  the  sphincter;  it  should  have  a  slightly  bulbous  end 
with  large  holes.  The  size  of  the  holes,  as  Murphy  insists,  is  of 
the  first  importance;  for  through  ample  apertures  not  only  can 
the  saline  flow  into  the  rectum  easily,  but  flatus  can  escape 
through  them,  or  the  saline  be  forced  back  in  an  effort  of  strain- 
ing, so  that  no  fluid  is  expelled  by  the  side  of  the  tube.  More- 
over large  openings  are  less  likely  to  be  blocked  by  faeces  than 
small  ones.  The  fluid  is  introduced  approximately  at  the  rate 
of  I  pint  an  hour  for  the  first  six  or  eight  hours,  then  more  slowly 
if  the  patient's  needs  are  being  satisfied.  I  employ  the  method 
in  a  great  many  cases :  indeed,  in  all  of  any  formidable  character. 
(See  "Lancet,"  August  17,  1907.) 

Every  twenty-four  hours  the  rectum  is  washed  out  with 
a  pint  of  hot  water  and  soap.  If  flatus  cannot  be  passed 
freely,  a  tablespoonful  of  turpentine  is  added  to  the  enema. 
I  find  an  enema  of  two  ounces  of  glycerine  and  two  ounces  of 
water  useful  occasionally.  The  majority  of  abdominal  cases  are 
given  one  ounce  of  paraffin  night  and  morning  on  the  second  and 
subsequent  days. 

The  rectal  tube  is  passed  occasionally  if  thought  necessary. 

In  the  great  majority  of  cases  no  bandage  is  needed.  Three 
or  four  narrow  layers  of  gauze  are  applied  over  the  wound  in  all 
its  length.  Over  these  a  large  square  piece  of  gauze  is  placed, 
and  its  edges  are  sealed  to  the  skin  by  the  application  of  a  formalin 
and  gelatin  mixture.  One  ounce  of  gelatin  sterilised  by  heating 
to  100°  C.  oh  three  successive  days  in  a  test-tube  is  warmed  until 


■O^'T}'     '\W' 


KS 


60 


A  line  )M  IV  ^ 


I       <  tIM.  U    \ 


I  do  not  allow  the  calljcUi  : 
If  there  is  (liHiculty  in  voiding  v. 
will  {j^enerally  1)C  helpful.  If  n«»  u: 
of  twenty-four  hours  or  if  the  1 
I  he-  catheter  is  passed,  with  all  the 
])atients  are  found  to  pass  a  s- 
tlirec  <»r  four  ounces,  frequentlv 
found  that  they  have 
terism  will  then  be  neeebhar\ . 

An  exact  record  should   l>e   k'  ■  • 
passed  until  all  danger  from  the 

Ivccial    injections    of    salino 
in\arial)Iy    for   twenty-four  01 
is    to   say,   the    patient   is   gettn 
by  the  mouth.      I  do  not  give  • 
Salt  and   water,  one  t« 
brandy,  forms  the  usual  rm  mm 
or  more  as  seems  desirable,  ev<'r\ 
may  occasionally  lie  given  in 
needed  by  the  patient,  and  anytl 
nutrient  enema  is  of  no  value. 

Among   the  most  imix)rtani    r 
treatment  of  patients  submitted  l< 
kind,  the  method  of  proctoclysis 
is  undoubtedly  the  chief.     The  ab 
rectum  alters  the  whole  aspect  of 
the  appearance  of  the  patient  is  ^ 
red  and  the  eyes  clear;  the  skin  a« 
abolished  and  the  pulse  keeps  fu" 
fluid  wliioh  can  be  absorbed  in  thi 
have  on  manv  occasions  adminisicrc 


a    rule. 

mentation 

^    'he  end 

ruble, 

Some 

urine, 

i    y^ul    generally     be 

•^.  and  cathe- 

'    uruic 

ilmost 

.til.    that 

of    fhiid 

•   <-ncma. 

■  r  unthout 

f  ten  ounces 

"-^     niucose 

■  li.a  is 

n  in  a  so-called 

>ns  to  the  after- 

ns  of  any 
y  J.  ii.  Murphy 
•  fluid  by  the 
ngerous  case; 
. :  the  lips  are 
•rst  is  lessened  or 
•w.  The  amount  of 
very  remarkable.  I 
<  OT  more  within 
twenty-four  hours.  Probably  this  is  m*  .rt  n.t:i  is  necessary  or  de- 
sirable; 10  or  12  pints  should  be  all  thais  needed.  If  a  large 
quantity  is  absorbed  the  face  and  hands  my  l>ecome  oedematous. 
The  strain  thrown  upon  the  kidneys,  espetUly  if  they  are  not  fully 


vFti:r-trkatme\t. 


61 


competent,  by  the  ;  hinistration  of  so  much  water  and  so  large 
a  dose  of  salt,  may  }m  factor  not  always  to  be  ignored;  never- 
theless in  my  own  oxprience  nothing  but  good  has  resulted  trom 
this  lavish  administraon  of  fluids.  It  is  possible  that  the  colon 
ceases  to  absorb  wh«  ahe  needs  of  the  body  are  satisfied. 

The  mode  of  adiniistration  best  adapted  tor  the  pun>ose  is 
that  originally  inlndced  l)y  Mun)]iy:  there  have  been  several 
subsequent  mo  is  by  other  surgeons.   l)ut   no  improve- 

ments. The  cannuiavhich  lies  in  tlie  rectum  should  reach  a 
little  above  the  sphiruer;  it  should  have  a  slightly  bulbous  end 
with  large  holes,  'nnsize  of  the  holes,  as  Murphy  insists,  is  of 
the  first  importan(  <  .  ,)r  through  ample  apertures  not  only  can 
the  saline  flow  i- •  he  rectum  easily,  but  flatus  can  escape 
through  them,  '  line  be  forced  back  in  an  elTort  of  strain- 

ing, so  that  no  fluid  ifc.xpelled  by  the  side  of  thi'  tube.  More- 
over large  openings  :ij  less  likely  to  be  blocki'd  by  f;eces  than 
small  ones.  The  fluids  introduced  aiii)roximately  at  the  rate 
of  I  pint  an  hour  for  it  first  six  or  eight  hours,  then  more  slowly 
if  the  patient's  needs  a^  lieing  satisfied.  I  employ  the  method 
in  a  great  manv  r  t-.  rindeed,  in  all  of  any  formidable  character. 
(See  "Lami  17    1907.) 

Every   twei  hours  the   rectum   is   washed  out  with 

a  pint  of  hot  watcrfnd  soap.  If  flatus  cannot  be  passed 
freely,  a   tables  of  turpentine  is  added  to  the  enema. 

I  find  an  enema  ui  >.v>  ounces  of  glycerine  and  two  ounces  of 
water  useful  occasional^-.  The  majority  of  abdominal  cases  are 
given  one  ounce  <.r  :  iffin  night  and  morning  on  the  second anH 
subsequent  day 

The  rectal  tub<  -d  occasionally  if  thought  necessary. 

In  the  great  maioiy  of  cases  no  bandage  is  needed.    Three 
or  four  narrow  layers     gauze  are  applied  over  the  wound  in  all 
its  length.     Over  thes  a  large  square  piece  of  gauze  is  placed, 
and  its  edges  are  sealeclD  the  skin  by  the  apphcation  of  a/<"-. 
aud  gelatin  mixture,     te  ounce  of  gelatin  sterili.sed  by  ) 
to  100"  C.  oh  three  su<tssive  days  in  a  test-tube  is  warnic 


64  ABDOMINAL   OPERATIONS. 

If  all  is  going  well,  the  sooner  a  patient  is  up  the  better. 
A  patient,  for  example,  after  the  removal  of  an  appendix 
may  be  out  of  bed  in  six  or  seven  days  and  may  return 
to  light  work  in  a  fortnight.  A  feeble  patient,  after  the 
operation  of  gastro-enterostomy, — an  old  man  with  malignant 
disease,  for  example, — may  be  allowed  to  sit  up  in  a  chair 
on  the  fourth  or  fifth  day.  One  patient,  a  medical  man 
upon  whom  I  performed  gastro-enterostomy  and  chole- 
cystotomy,  was  seeing  patients  on  the  fifteenth  day  after 
his  operation,  and,  though  this  was  done  without  my  sanc- 
tion, no  ill  effects  followed.  In  all  cases,  however,  the 
discretion  of  the  surgeon  must  decide  the  practice  in  each 
individual  case;  no  hard-and-fast  rule  can  be  laid  down. 
All  that  can  be  positively  said  is  that,  provided  all  symp- 
toms are  favourable,  there  should  be  no  unnecessary  delay 
in  allowing  the'  patient  to  sit  up. 

If  a  patient  is  much  enfeebled  and  wasted,  I  frequently 
order  massage  to  the  extremities  within  the  first  few  days 
after  operation.  This  is  found  most  grateful  to  the  patient, 
and  prevents  a  feeling  of  extreme  weakness  when  he  is 
allowed  to  get  out  of  bed. 

During  the  whole  of  the  time  that  the  patient  remains 
under  treatment  after  operation  the  most  scrupulous  atten- 
tion is  bestowed  upon  the  toilet  of  the  mouth.  The  teeth 
are  brushed  frequently  and  some  fragrant  mouth-wash  is 
used  as  often  as  possible.  If  the  mouth  is  kept  clean,  the 
feeling  of  thirst  is  less  noticeable.  All  fluid  foods  given  are 
sterilised,  both  before  and  after  the  operation.  ' 

When  drainage  is  employed,  the  tubes  will  need  daily 
attention.  If  a  drainage-tube  is  left  in  the  wound,  to  drain 
the  gall-bladder  or  the  common  duct,  its  outer  end  is  fitted 
into  a  bottle  of  about  ten  ounces  capacity  which  is  jfixed  by  a 
safety-pin  to  the  side  of  the  dressing.  During  the  first  few 
hours  bile  may  flow  in  very  small  quantity,  especially  in  cases 
where  the  action  of  the   hepatic  cells   has  been   in   part   sup- 


AFTER-TREATMENT,  65 

pressed  by  the  tension  and  sepsis  in  the  common  and  hepatic 
ducts,  as  a  result  of  the  occlusion  of  the  duct  by  a  stone. 
The  bile  that  first  flows  may  be  muddy  or  turbid,  but  after 
a  few  days  the  bile  flows  in  greater  quantity  and  it  becomes 
gradually  clearer.  The  tube  will  then  be  removed  if  the 
stitch  with  which  it  is  fixed  has  loosened. 

If  gauze  packing  has  been  used  as  a  barrier  around  the 
gall-bladder  in  cases  of  acute  cholecystitis,  or  elsewhere,  it  may 
be  left  until  it  has  loosened — say,  for  eight  days.  Its  removal 
then  is  almost  painless.  If  the  condition  which  has  necessitated 
drainage  is  septic  and  oft'ensive,  a  split  rubber  tube  will  per- 
haps have  been  introduced ;  this  tube  may  be  left  in  several  days 
and  shortened  daily  before  its  complete  removal.  Into  the 
track  left  after  its  removal  sterile  vaseline  or  paraffin  may  be 
poured. 

REFERENCES. 
Yates,   "Surgery,  Gynaecology  and  Obstetrics,"  December,  1905,  p.  473  (where 

a  full  list  of  references  is  given). 
Clark,   "American  Journal  of  Obstetrics,"  1S97,  PP-  481.  650. 


CHAPTER  III. 

THE  COMPLICATIONS  AND  SEQUELS  OF  ABDOMINAL 
OPERATIONS. 

There  are  chiefly  six: 

1.  Peritonitis. 

2.  Liing  complications. 

3.  Parotitis. 

4.  Post-operative  haeniatemesis. 

5.  Acute  dilatation  of  the  stomach. 

6.  Phlebitis  and  thrombosis. 

Peritonitis. — The  occurrence  of  peritonitis  after  abdom- 
inal operations  has  almost  been  abolished  by  the  careful 
methods  of  modern  surgery.  In  some  cases,  however,  the 
risk  of  it  cannot  be  avoided,  for  the  operation  ma}^  involve 
the  handling  of  the  lumen  of  the  stomach  or  intestine 
which  is  septic,  and  from  which  the  escape  of  organisms 
cannot  w^hoUy  be  prevented. 

The  careful  preparation  before  operation  will  often  effect 
a  great  reduction  in  the  number  and  virulence  of  organisms 
in  the  stomach  and  the  upper  part  of  the  intestine,  as 
is  elsewhere  pointed  out,  but  an  adequate  preparation  is 
not  always  possible — as,  for  example,  in  cases  of  malignant 
disease  of  the  stomach  or  in  any  form  of  acute  disease 
of  the  stomach  or  intestine  requiring  urgent  operation.  The 
methods  of  preparation,  the  use  of  clamps  to  prevent  leak- 
age of  contents  in  such  operations,  and  the  details  of  an 
aseptic  operation  faithfully  observed  have,  however,  done 
much  to  prevent  the  occurrence  of  any  septic  infection  of 
the  peritoneum.  Nevertheless,  peritonitis  does  occur,  and  is 
perhaps  the  most  serious,  if  the  least  frequent,  of  all  the 
complications  of  an  abdominal  operation. 

66 


THE   COMPLICATIONS   AND    SEQUELS.  6/ 

It  has  long  been  a  matter  of  earnest  enquiry  among 
surgeons  as  to  whether  it  would  not  be  possible,  by  some 
preventive  inoculation,  to  render  a  patient  more  capable 
of  withstanding  the  infection,  during  an  operation,  with 
any  septic  organisms.  Experiments  have  been  performed 
in  the  hope  of  discovering  some  means  by  which  the  danger 
of  a  peritoneal  infection  can  be  greatly  diminished,  and 
among  these  means  prominence  must  be  given  to  the  pro- 
duction of  hyperleucocytosis.  The  first  investigators  were 
Loewy  and  Richter,  who  attempted,  by  the  injection  of 
albumoses,  especially  spermin,  to  produce  a  hyperleucocy- 
tosis, and  thereby  to  make  the  animals  capable  of  resisting 
infection  by  pneumococci.  Jakob,  by  the  intravenous  and 
subcutaneous  injection  of  albumose  into  rabbits,  made  them 
proof  against  pneumococci  and  the  organisms  of  mouse 
septicaemia.  It  was  noticed  that  after  each  injection  a 
hypoleucocytosis  occurred  first,  to  be  followed  speedily  by 
hyperleucocytosis.  If  the  infection  was  brought  about 
during  the  time  w^hen  the  leucocytes  were  diminished,  the 
animals  without  exception  died;  if,  on  the  other  hand, 
the  infection  was  introduced  during  the  time  when  the 
leucocytes  were  increased,  the  course  of  the  disease  was 
influenced  in  the  most  favourable  way.  Hahn  succeeded 
in  shewing  that  during  the  stage  of  artificial  hyperleu- 
cocytosis, produced  by  nuclein  and  tuberculin,  the  blood 
of  men  and  dogs  possessed  a  higher  bactericidal  value 
than  normal  blood.  Hofbauer,  in  Vienna,  has  obtained  fa- 
vourable results  in  undoubted  puerperal  septicaemia  by  the 
administration  of  five  or  six  grains  of  nuclein  by  the  mouth. 
After  reviewing  these  facts  Professor  von  ^Mikulicz,  from 
whom  they  are  quoted,  writes  ("  Lancet,"  July   2,  1904): 

"The  question  arises  whether  artificial  hyperleucocytosis 
may  not  be  of  value  in  practice  as  a  prophylactic.  Ac- 
cording to  the  above-mentioned  experiments  of  Loewy  and 
Richter,  of    Jakob    and    Halm,  one    cannot    exclude    the    pos- 


68  ABDOMINAL   OPER.\TIONS. 

sibility  that,  by  a  parth^  anticipated  mobilisation  of  great 
masses  of  leucocytes,  the  latter  may  overcome  the  bacteria 
which  had  obtained  entrance  in  the  first  instance  in 
relatively  small  masses  with  greater  ease  than  if  the  leuco- 
cytes delay  their  attack  in  force  until  the  number  and 
virulence  of  the  bacteria  in  the  tissues  have  markedly 
increased." 

A  series  of  experiments  conducted  by  J\Iiyake  and  au- 
thorised by  Professor  ]\likulicz  resulted  in  evidence  that 
the  injection  of  nuclein  in  animals  prior  to  the  infection 
of  the  peritoneal  cavity  by  organisms  had  an  undoubted 
effect  in  lessening  the  occurrence  of  peritonitis.  Some  of 
these  experiments  ' '  consisted  in  performing  a  laparotomy 
and  forcing  through  an  opening  in  the  stomach  or  intestine 
as  much  of  their  contents  as  could  be  obtained  from  the 
immediate  neighbourhood  of  the  incision.  Of  five  control 
animals  which  had  not  been  previously  prepared,  four  died 
from  peritonitis  between  five  and  sixteen  hours  after  the 
operation.  The  fifth  became  extremely  ill,  but  finall}' 
recovered,  but  the  amount  of  intestinal  contents  which 
was  transferred  to  the  peritoneum  was  less  in  this  case 
than  in  the  others.  Ten  animals  were  prepared.  These 
recovered  without  exception.  The  preparation  consisted  in 
three  intraperitoneal  injections  of  nucleic  acid,  two  injections 
of  neutralised  nucleic  acid.  In  each  case  laparotomy  was 
performed  seven  hours  after  the  injection.  These  experi- 
ments are  such  as  to  excite  our  interest  in  the  highest 
degree,  for  by  subcutaneous  injections  of  nucleic  acid  it 
was  possible  to  raise  the  resistance  of  the  peritoneum  to 
such  an  extent  that  even  a  considerable  quantit}^  of  in- 
testinal contents  could  be  placed  in  the  peritoneal  cavity 
without  causing  damage,  whilst  without  previous  treatment 
an  acute,  rapidly  fatal  peritonitis  followed  almost  without 
exception.  This  opens  out  a  new  field  for  the  surgeon 
in  preventing  post-operative  peritonitis." 

In  adopting  the  results  of  these  experiments  for  the 
purposes  of  operations  upon  man,  Mikulicz  has  administered 
fifty  cubic  centimetres  of  neutralised  nucleic  acid,  2   per  cent., 


THE   COMPLICATIONS   AND    SEQUELS.  69 

and    has    finally    settled    upon    allowing    a    period    of    twelve 
hours  to  elapse  between  the  injection  and  the  operation. 

In  view  of  the  novelty  and  importance  of  this  subject, 
I  may  be  permitted  to  quote  the  following  summary  of 
his  experiments  from  Professor  Mikulicz's  article: 

"The  number  of  my  experiments  is  not  sufficient  to 
permit  me  to  form  a  definite  judgment  upon  these  points 
and  to  give  an  unguarded  reply.  We  cannot,  in  the  case 
of  man,  as  we  do  in  that  of  the  lower  animals  when  in- 
troducing infective  material  into  the  abdominal  cavity, 
give  a  certain  multiple  of  the  minimum  lethal  dose  in 
order  to  see  how  far  a  preventive  treatment  has  succeeded. 
We  set  all  our  apparatus  in  action,  in  spite  of  preven- 
tive inoculation,  to  reduce  infection  to  the  minimum.  Since 
this  method  fortunately  succeeds  in  the  majority  of  cases, 
even  without  preventive  inoculation,  in  guarding  the  patients 
from  a  fatal  peritonitis,  a  small  number  of  satisfactory 
results  do  not  prove  much;  but,  on  the  other  hand,  one 
or  two  unsatisfactory  results  most  certainly  cannot  condemn 
the  method,  for  this  method  gives  not  absolute  certainty 
like  a  specific  immunisation,  but  only  increases  the  natural 
immunity,  and  this  may,  in  certain  circumstances,  even 
when  increased  to  thirty-fold,  nevertheless  be  insufficient. 
I  have,  however,  the  impression  that  the  cases  hitherto 
treated  have  given  more  favourable  results,  not  only  in 
the  number  of  cases  that  recovered,  but  also  in  the  progress 
of  the  individual  cases,  than  the  analogous  cases  of  earlier 
date  where  the  operation  was  performed  without  this  prepa- 
ration. In  10  cases  of  resection  of  the  stomach  for  car- 
cinoma, 9  recovered,  6  of  them  without  the  slightest  com- 
plication. The  progress  was  marked  by  a  smoothness 
that  was  quite  exceptional  before  this  treatment  w'as  adopted. 
Two  cases  which  presented  exceptional  difficulty  in  the 
removal  of  the  carcinoma  did  undoubtedly  within  twenty- 
four  hours  develop  peritonitis,  with  a  pulse  up  to  160, 
which,  according  to  our  usual  experience,  foretold  the  most 
dismal  prognosis.  The  patients  fortunately  survived  this 
peritonitis.  In  the  ninth  case  which  recovered,  the  progress 
was    disturbed    from    the    fourth    day    by   broncho-pneumonia. 


70 


ABDOMINAL   OPERATION. 


The    tenth    case    died;     after    seven    days    of    uninterrupted 
progress    he    developed    pneumonia,  to    which    he    succumbed 
three    weeks    after   the    operation.      Of    the    remaining    opera- 
tions   I    should    like    to    refer    first    to    22    cases    of    gastro- 
enterostomy and    entero-anastomosis,  12    of    which    were    for 
carcinoma.      Of    these    cases,  19    recovered    and    3    died.     In 
all    3     cases    death    was    most    certainly    not    due    to    post- 
operative   peritonitis,  but    in     i     case    to    perforation    of    an 
ulcerated    carcinoma    of    the    stomach    two    weeks    after    the 
operation;    in   another   case,   to    continued    haemorrhage    from 
a    carcinoma    of    the    stomach    sixteen    days    after   the    opera- 
tion;   and  in   the   third,    to   peritonitis   arising  '  from   a   tuber- 
culous   granuloma    in    the    intestine    four    weeks    after    opera- 
tion.      Of    6  cases    of    resection    of    the    intestines     at     one 
operation,    4    recovered    and    2    died.       In    i    case    death    oc- 
curred   from    collapse    on   the    second    day    after    a    very    pro- 
longed    operation     of     double     resection     for     carcinoma;     in 
the  other  case,  where  the  injury  was   a  bullet  wound,   death 
took    place    on    the    tenth    day    from    hemorrhage    from    the 
vena    cava.       In    neither    of    the    cases    was    there    any    peri- 
tonitis.     One    case    of    opening    the    stomach    and    stretching 
the    cardiac    orifice,  performed    on    account    of    spasm,  recov- 
ered.     So    also    did    6    cases    of    operation    on    the   bile-duct, 
7    other    operations    upon    abdominal    organs    without    open- 
ing   the    intestinal    tract,   and    3    extra-abdominal    operations. 
The    last    to    be    mentioned    are    two    cases    of    nephrectomy, 
which   were   treated   before    the    operation   with   nucleic    acid. 
In   both   cases,  in   order   to   remove    the   suppurating   kidney, 
the    peritoneum    had    to    be    widely    opened.      One    case    re- 
covered;   the    other    died    twelve    days    after    the    operation 
from    hsemorrhage    from    the    renal    artery.       In    this     case, 
too,  there   was   no    peritonitis.      We    therefore   have    45    lapa- 
rotomies   in    which    the    abdominal    cavity    was    exposed    to 
infection    by    the    contents    of    the    stomach    or    intestines    or 
by    some    other    infectious    secretion;    38    of    these    cases    re- 
covered, and   in    none    of   the    7    fatal   results    was    peritonitis 
the  cause  of  death." 

In    addition    to    these    measures    there    are    others    which 
have    been    used    for    the    purpose    of    warding    off   an   attack 


THE   COMPLICATIONS   AND    SEQUELS.  7 1 

of  peritonitis  or  of  combating  its  effects  in  the  earlier 
stage.  The  chief  among  them  is  the  inoculation  with 
antistreptococcic  serum.  The  use  of  this  has  been  vaunted 
by  Kader,  but  the  general  experience  of  surgeons  tends  to 
shew  that  it  is  of  very  little  value,  if,  indeed,  it  has  any 
value  at  all. 

The  free  lavage  of  the  peritoneum  with  hot  saline  solu- 
tion, of  which  a  large  quantity  is  left  within  the  abdomen 
when  the  wound  is  closed,  has  been  shewn  to  lessen  the 
likelihood  of  peritoneal  infection,  and  to  render  the  peri- 
toneum better  able  to  deal  with  the  organisms  which  attack 
it.  It  has  become  a  practice  among  many  surgeons  of 
great  experience,  ]^Iikulicz  among  them,  to  employ  this 
drenching  of  the  peritoneum  more  and  more.  It  is  not 
a  method  which  has  ever  appealed  to  me,  and  it  is  not 
my  practice  to  flush  the  peritoneum  except  in  infected 
cases  where  there  are  gross  particles  either  of  septic  material, 
lymph,  or  of  food  stuffs. 

Peritonitis  is  to  be  suspected  when,  after  operation, 
pain,  instead  of  subsiding,  graduall}'  becomes  more  and 
more  intense,  when  the  abdomen  becomes  prominent  and 
tympanitic,  and  the  intestines  distended  and  motionless. 
In  such  circumstances  the  pulse  gives  the  surest  indication 
of  the  patient's  condition.  When  the  pulse  rises  steadily 
in  frequency  and  its  quality  becomes  progressively  poorer, 
a  most  serious  condition  is  present  or  impending.  AVhen 
the  pulse-rate  is  below  loo  there  is,  as  a  rule,  no  cause 
for  anxiety;  but  with  a  pulse-rate  rising  gradually  from 
1 20  to  140  or  even  higher,  in  the  absence  of  chest  com- 
plications, the  existence  of  peritonitis  may  be  confidently 
predicted.  The  patient,  as  a  rule,  looks  anxious  and  care- 
worn and  wears  a  frowning  expression.  Cyanosis  and  cold, 
clammy  extremities  indicate  approaching  dissolution.  As 
a  rule,  there  is  some  elevation  of  temperature  in  the  early 
stages ;  but  later  the  temperature  may  be  normal  or  subnormal. 


72  ABDOMINAL   OPERATIONS. 

It  is  a  factor  of  little  importance.  The  patient  lies  with 
his  hands  above  his  head  and  his  knees  drawn  up ;  straight- 
ening the  thighs  causes  an  increase  in  the  abdominal  pain. 
A^omiting  and  hiccough  are  sometimes  persistent.  An  ounce 
or  two  of  fluid,  perhaps  stained  black  by  digested  blood, 
may  be  vomited  every  few  minutes,  and,  though  lavage 
relieves  this  symptom  for  a  time,  it  is  almost  certain  to 
return.  As  the  toxaemia  deepens  the  patient  gradually 
becomes  numbed  to  his  pain,  and  will  often  express  himself 
as  feeling  much  easier;  this  is  a  bad  sign.  The  skin  is 
dr}^  until  near  the  end,  Avhen  a  cold  sweat  covers  the 
patient.  The  tongue  is  dry  and  coated,  and  the  secretions 
all  are  scanty.  It  is,  however,  the  steadily  increasing 
rapidity  in  the  pulse-rate,  together  with  a  steady  fall  in 
the  character  of  the  pulse,  that  gives  most  cause  for  anxiety. 

As  soon  as  the  indications  of  a  commencing  peritonitis 
are  observed,  measures  must  at  once  be  taken  to  secure 
a  free  action  of  the  bowels.  If  a  copious  evacuation  of 
flatus  or  fasces  can  be  compelled,  the  great  probability 
is  that  the  patient  can  be  saved.  Unfortunately,  the  ad- 
ministration of  any  aperient  by  the  mouth  is  little  likely 
to  be  of  use,  for  the  drug  will  often  be  vomited  within 
a  few  minutes.  Enemata  containing  turpentine  or  enemata 
of  oil  introduced  high  into  the  colon  are  the  chief  measures 
upon  which  reliance  must  be  placed.  One  of  the  things 
most  needed  in  therapeutics  is  an  aperient  that  can  be 
administered  hypodermically.  Sulphate  of  eserine  in  y^^  gr. 
to  jr^jj  gr.  doses  may  be  employed  or  pituitary  extract,  as  first 
advised  by  Blair  Bell. 

Is  it  worth  while,  in  cases  of  general  peritonitis,  to 
reopen  the  abdomen  and  to  attempt  to  cleanse  and  to 
drain  it?  The  infection  which  underlies  the  symptoms 
mentioned  above  is  so  universal  that  any  operative  treat- 
ment would  be  in  itself  a  most  hazardous  procedure,  when 
applied    to    a    patient    who    has    already    borne    the    strain 


THE   COMPLICATIONS   AND    SEQUELS.  73 

of  a  serious  operation.  In  the  early  stage  of  these  cases 
one  has  hope  of  being  able  to  cut  short  the  disease  by 
brisk  purgation.  When  this  has  failed,  the  patient's  con- 
dition is  such  that  little  hope  of  relief  can  be  entertained. 
There  are  cases,  however, — though  in  my  opinion  they 
are  few, — when  a  reopening  of  the  abdomen  is  not  only  justi- 
fied, but  is  absolutely  necessary  if  the  patient  is  to  be  saved. 
These  are  the  cases  where  the  infection  can  be  traced  with 
reasonable  certainty  to  a  definite  source;  such  as,  for  example, 
leakage  from  the  giving  way  of  an  anastomosis  accomplished  by 
the  Murphy  button  or  by  suture,  or  soiling  due  to  the  escape  of 
infective  material  from  the  intestine  during  the  operation.  In 
such  circumstances  the  continued  infection  must  be  stopped  by 
appropriate  measures  of  repair,  and  the  soiled  parts  must 
be  thoroughly  cleansed,  and,  if  need  be,  drainage  must  be 
established.  Should  a  generalised  post-operative  peritonitis 
occur,  the  treatment  does  not  differ  from  that  of  peritonitis  due 
to  an  appendix,  a  perforated  ulcer,  or  any  other  lesion, — namely, 
suppression  of  the  cause,  little  or  no  irrigation  and  no  free  hand- 
ling of  intestines ;  Fowler's  posture  should  be  adopted  to  facilitate 
respiration  and  to  collect  fluid  in  the  pelvis  and  thus  preserve  ' 
the  most  absorptive  portion  of  the  serosa.  Proctoclysis  here  is 
invaluable  and  gastric  lavage  may  be  necessary. 

Lung  Complications. — Chest  complications  formerly  oc- 
curred frequently  after  abdominal  operations.  In  the  surgery 
of  the  present  day  their  occurrence,  though  greatly  dimin- 
ished, is   still   far   greater   than   it   should   be. 

The  following  lung  complications  are  known  to  follow 
any  abdominal  operation:  pneumonia;  pleurisy;  bronchitis; 
oedema  of  lungs ;  abscess  of  lung ;  massive  collapse ;  pulmonary 
embolism ;  gangrene  of  the  lung.  Any  one  of  these  may  follow 
a  simple  or  a  serious  operation,  a  short,  or  a  prolonged  one.  The 
cause  of  the  lung  implication  has  been  closely  investigated,  and 
a  variety  of  explanations  have  been  offered.  The  suggestion 
was  long  ago  put  forward  with  confidence  that  the  anaesthetic 


74  ABDOMINAL   OPERATIONS. 

was  the  responsible  agent.  The  chilling  and  irritating  effect  of 
ether  upon  the  mucous  membrane  of  the  respiratory  tract 
resulted  in  a  profuse  secretion  from  the  inflamed  surface.  The 
aspiration  of  saliva  has  also  been  blamed.  It  was  not  long,  how- 
ever, before  it  was  found  that  all  these  chest  troubles  might  fol- 
low upon  operations  which  were  performed  under  local  anees- 
thesia  alone. 

It  is  well  known  that  for  a  few  days  after  any  ab- 
dominal operation  the  wound  may  feel  stiff  and  sore,  though 
it  is  not  actually  painful.  The  taking  of  a  deep  breath  or 
the  act  of  coughing  causes  a  sudden  "stitch"  in  the  wound, 
and  the  patient  feels  as  though  a  free  effort  at  coughing 
would  tear  the  wound  edges  apart.  It  was  suggested  then 
that  the  immobilisation  of  the  abdominal  muscles,  in  the 
unconscious  protection  of  the  wound  area  by  the  patient, 
resulted  in  an  accumulation  of  the  bronchial  secretions  in 
the  lung.  A  deep  breath  was  not  taken;  the  breathing 
remained  thoracic  in  type,  and  the  air-passages  were  not 
cleared  in  the  act  of  coughing.  The  lung  then  became 
irritated  and  waterlogged  by  retained  secretions.  In  favour 
of  this  suggestion  is  the  fact  that  all  forms  of  chest  in- 
volvement are  more  frequent  after  operations  performed 
in  the  upper  abdomen.  Statistics  from  Korte's  clinic  shew  lo  per 
cent,  pulmonary  complications  in  operations  above  the  umbilicus 
and  6.6  per  cent,  in  operations  where  the  abdomen  was  opened 
below  the  umbilicus.  W.  Pasteur  ("Lancet,"  Oct.,  1910)  believes 
massive  collapse  of  a  lung  after  abdominal  operations  to  be  a  di- 
rect result  of  reflex  inhibition  of  the  diaphragm  causing  deflation  of 
the  pulmonary  bases.  He  writes:  "Whenever — whether  as  the 
result  of  paralysis  or  of  temporary  reflex  inhibition  of  muscular 
action — the  distending  force  acting  on  the  lungs  becomes  less  than 
that  of  the  elastic  and  muscular  agencies  which  tend  to  cause  its 
contraction,  these  latter,  so  to  speak,  take  charge,  with  the  result 
that  the  affected  portion  of  the  lung  rapidly  empties  itself  of  its 
contained  air."     It  is  quite  possible  that  in  patients  operated 


THE   COMPLICATIONS   AND    SEQUELS.  75 

upon  for  conditions  in  the  upper  abdomen  pleurisy  is  often  the 
result  of  a  post-operative  inflammatory  reaction  extending  to  the 
diaphragm  and  pleura. 

A  factor  which  is,  without  question,  one  of  great  im- 
portance is  the  chilling  of  the  patient  before,  during,  and 
after  the  operation.  It  was,  at  one  time,  the  custom  in 
many  hospitals  to  send  all  the  patients  to  the  bath  on 
their  arrival.  After  the  bath,  a  thin  cotton  shirt  w^as 
given  to  them — no  matter  what  form  of  clothing  had  been 
worn  on  admission.  Furthermore,  during  the  operation, 
in  a  room  perhaps  not  overwarm,  a  considerable  part  of 
the  patient's  body  was  exposed,  and  if  the  cleansing  of 
the  skin  were  done  by  a  house-surgeon  fond  of  a  splash, 
a  pint  or  two  of  lotion  was  allowed  to  run  down  under- 
neath the  patient.  A  thinly  clad  patient,  most  of  whose 
abdomen  was  exposed,  was,  therefore,  lying  on  a  cold, 
damp  table  for  perhaps  an  hour — a  most  unsatisfactory 
condition  of  things. 

The  patient  should  have  warm  clothing  on  arrival; 
before  the  operation  he  should  be  clad  in  a  suit  of  gamgee 
pajamas ;  as  little  of  the  abdomen  as  possible  (though  as 
much  as  is  necessary)  should  be  exposed;  the  operation 
room  should  be  well  warmed;  if  necessary,  the  table  should 
be  a  hot-water  table ;  operations  should  be  done  expedi- 
tiously. There  should,  moreover,  never  be  undue  exposure 
or  handling  of  viscera,  so  that  no  unnecessary  shock  may 
be  caused. 

In  some  cases  I  feel  sure  that  the  cause  of  the  lung 
implication  is  to  be  found  in  the  inhalation  of  septic  matter. 
This  septic  matter  may  come  from  the  patient's  own  mouth, 
or  it  is  conceivable  that  a  dirty  inhaler  may  be  responsible 
for  it.  Of  the  necessity  for  cleanliness  in  both  these  direc- 
tions there  is  no  further  need  to  speak. 

In  some  cases  the  pneumonia  has  been  proved  to  be 
due     to     embolism,  the     septic     emboli     being     derived     from 


76  ABDOMINAL   OPERATIONS. 

the  operation  area.  In  operations  upon  the  stomach  or 
intestine  in  particular,  thrombosis  of  veins  may  result  from 
unduly  rough  handling  or  from  infection  of  the  wounds. 
Neatness  and  a  certain  dainty  fastidiousness  and  the  utmost 
cleanliness  in  all  operations   are  things  to  be  cultivated. 

There  can  be  little  doubt,  I  think,  that  in  some  cases 
the  long  continuance  of  the  Trendelenburg  position  in 
pelvic  operations  is  productive  of  harm.  The  viscera  are 
pressed  against  the  diaphragm,  whose  freedom  of  action 
is  thereby  limited.  There  is  congestion  of  the  lungs  as 
a  result  of  the  gravitation  of  blood  to  the  dependent  parts. 
It  is  my  custom  to  perform  the  early  and  late  steps  of 
any  pelvic  operation  with  the  patient  in  the  usual  hori- 
zontal position.  As  soon  as  the  Trendelenburg  position  is 
necessar\^,  the  table  is  altered  b}^  the  anesthetist  in  a 
moment;  as  soon  as  the  pelvic  part  of  the  operation  is 
completed,  the  table  is  again  made  horizontal.  The  patient,- 
therefore,  remains  the  briefest  possible  time  in  this  con- 
strained position. 

It  has  become  a  general  custom,  more  especially  among 
resident  officers,  to  give  intravenous  saline  injections  to 
all  patients  who  are  suffering  in  any  serious  degree  from 
shock.  The  custom  has  much  to  recommend  it,  but  I 
am  strongly  disposed  to  think  that  it  is  not  seldom  provo- 
cative of  harm,  for,  in  some  cases,  when  large  quantities  of 
fluid  are  injected,  an  acute  oedema  of  the  lung,  with  copious 
frothy  expectoration,  occurs.  On  postmortem  examination 
of  such  cases  it  can  be  seen  that  there  is  an  acute  oedema 
of  both  lungs;  the  lungs,  in  fact,  are  waterlogged.  Saline 
infusions  are  remedies  we  cannot  afford  to  do  without, 
but  a  little  more  discretion  than  seems  to  be  generally 
customary  should  be  exercised  in  their  administration. 
Above  all,  it  should  be  seen  that  the  fluid  injected  is  of 
proper  temperature,  that  no  air  is  allowed  to  get  into 
the    vein,  and    that    the    quantity    injected    does    not    exceed 


THE   COMPLICATIONS   AND    SEQUELS.  ']'] 

three  pints.  As  much  as  five  or  six  pints  have  been  fre- 
quently given;  but  I  do  not  think  that  as  much  benefit 
results  from  one  large  injection  as  from  two  smaller  ones 
given  with  an  interval  of  twelve  or  twenty-four  hours. 

Professor  Mikulicz  used  to  order  all  his  patients,  after  ab- 
dominal operations,  to  breathe  deeply  for  a  few  minutes 
two  or  three  times  daily  in  the  belief  that  the  tendency 
to  stagnation  in  the  lung  bases  is  thereby  relieved  and 
broncho-pneumonia   prevented. 

From  the  foregoing  discussion  it  will  be  realised  that, 
though  the  possible  causes  or  influences  giving  rise  to  the 
lung  complications  after  abdominal  operations  are  many, 
it  is  not  to  any  one  of  them  that  paramount  importance 
can  be  attached.  The  surgeon's  part,  therefore,  must  be 
to  safeguard  his  patient  by  all  the  means  in  his  power 
from  all  these  harmful  influences ;  and  he  will  find  that 
by  so  doing  the  risk  of  the  occurrence  of  these  most 
serious  disasters  will  be  greatly  lessened,  if  not  entirely 
abolished. 

The  treatment  of  the  lung  complications  following  ab- 
dominal operations  does  not  differ  from  that  which  is 
observed  in  the  cases  as  they  are  ordinarily  seen. 

I  have  come  to  place  much  reliance  upon  the  frequent 
use  of  the  steam  inhaler  with  or  without  tincture  of  benzoin 
or  other  stimulant.  The  patient  always  expresses  himself 
as  much  relieved  by  it,  and  a  copious  expectoration  generally 
results  from  each  use  of  the  inhaler.  A  mixture  contain- 
ing digitalis,  vinum  ipecacuanha,  and  carbonate  of  ammo- 
nium generally  gives  relief.  In  5835  major  operations  at  the 
Mayo  Clinic  pulrnonary  complications  occurred  in  89  cases  or 
.015  per  cent. 

Bibergeil  ("Archiv  f.  klin.  Chir.,"  Bd.  Ixxviii,  Heft  2,  and 
"Brit.  Med.  Journ.,"  Epitome,  March  17,  1906,  p.  41,  No.  170) 
publishes  the  results  of  an  analysis  of  3,909  abdominal  oper- 
ations, including  those  for  strangulated  and  reducible  hernia, 


78  ABDOMINAL   OPERATIONS. 

practised  in  Korte's  clinic,  and  points  out  what  he  concludes  to 
be  the  most  hkely  causes  of  postoperative  pneumonia  in  this 
class  of  cases.  Notwithstanding  the  protection  afforded  by 
modern  aseptic  methods  against  peritoneal  infection,  this 
pulmonary  complication  occurs,  it  is  stated,  more  frequently 
after  laparotomy  than  after  any  other  major  operation.  Pneu- 
monia followed  in  135  of  the  collected  cases,  and  presented  in 
10  instances  the  croupous  or  lobar,  in  98  the  lobular,  and  in 
the  remaining  27  the  hypostatic  form.  Other  complications, 
such  as  pulmonary  embolism  and  abscess,  bronchitis,  pleurisy, 
and  empyema,  occurred  in  147  other  cases.  In  this  study  of 
the  causes  of  pneumonia  in  abdominal  surgery,  the  author  finds 
that  the  occurrence  of  this  complication  is  not  influenced  in  any 
wa}^  b}^  the  condition  of  the  wound.  Of  10  cases  of  the  croupous 
and  distinctly  septic  form  of  pneumonia,  8,  so  far  as  the  seat  of 
operation  was  concerned,  were  aseptic,  and  2  only  were  septic. 
Careful  study  of  the  collected  cases  of  postoperative  pneumonia 
has  led,  he  states,  to  rejection  of  the  views  that  this  complica- 
tion may  be  due  to  infection  by  way  of  the  lymphatics,  and  to 
such  causes  as  exposure  to  cold  of  the  surface  of  the  body  or  of 
the  peritoneal  cavity  to  abdominal  irrigation,  and  to  direct 
action  of  a  general  anaesthetic.  The  lobular  form,  or  broncho- 
pneumonia, which  is  most  frequently  met  with  after  laparotomy, 
is  regarded  as  being  usualh^  the  result  of  autoinfection  due  to 
aspiration  of  secretions  from  the  mouth  and  pharynx  whilst 
the  patient  is  under  the  full  influence  of  an  anaesthetic.  It  is 
pointed  out  that  the  interference  with  free  breathing  and  ex- 
pectoration resulting  from  pain  at  the  seat  of  operation  and  im- 
peded movements  of  the  incised  abdominal  wall,  must  favour 
very  much  the  development  of  lung  disease  after  laparotomy, 
whilst  the  resistance  to  the  inflammatory  attack  is  in  many 
cases  much  impaired  in  consequence  of  the  enfeebled  condition 
of  the  patient.  In  concluding,  the  author  recommends,  as  suit- 
able prophylactic  measures,  thorough  cleansing  of  the  mouth  and 
throat  and  irrigation  of  the  stomach  before  the  operation;    a 


THE   COMPLICATIONS   AND    SEQUELS.  79 

cautious  administration  of  the  anaesthetic,  the  patient's  face 
being  turned  to  one  side  to  permit  a  free  external  flow  of  oral 
secretion ;  prevention  of  chilling  of  the  surface  of  the  abdomen 
during  and  after  the  operation;  the  application  of  thick  and 
warm  compresses  to  the  wound,  and  avoidance  of  tight  bandag- 
ing; frequent  change  of  the  patient's  position  in  bed  during  the 
after-treatment ;  and  as  speedy  a  release  from  the  recumbent 
posture  as  the  state  of  the  wound  will  allow. 

Parotitis. — An  acute  attack  of  inflammation  in  one  or  both 
parotid  glands  ma}^  follow  upon  an  operation  upon  any 
abdominal  organ.  I  feel  sure  that  the  frequency  of  this  most 
trying  complication  is  decidedly  less  than  it  was. 

In  1887,  Stephen  Paget  collected  the  records  of  10 1  cases, 
and  investigating  their  causes,  found  that  in — - 

10  cases  parotitis  arose  after  disease  or  injury  of  the  urinary  tract. 

18      "      parotitis  arose  after  disease  or  injury  of  the  alimentary  canal. 

23  "  parotitis  arose  after  disease  or  injury  of  the  abdominal  wall,  peri- 
toneum or  pelvic  cellular  tissue. 

50  "  parotitis  arose  after  disease  or  temporary  derangement  of  the  gen- 
erative organs. 

The  preponderance  in  this  series  of  cases  following  upon 
operations  upon  the  ovaries  was  doubtless  due  to  two  facts, — 
one,  that  at  the  time  these  cases  were  recorded  abdominal  sur- 
gery was  confined  very  largely  to  the  pelvic  organs ;  the  other, 
that  the  starvation  of  the  patient  was  considered  a  necessary 
incident  of  success ;  no  drop  of  water  was  given,  perhaps  for 
days,  and  the  mouth  was  parched,  the  tongue  dry  and  hard. 
In  those  days  the  surgery  of  the  stomach  and  gall-bladder  was 
in  its  earliest  infancy.  Operations  were  few,  and  patients 
were  not  often  fortunate  enough  to  survive  to  develop  parotitis. 

The  time  of  the  appearance  of  the  inflammation  is  usually 
towards  the  end  of  the  first  week  after  operation,  but  cases 
are  recorded  in  which  the  inflammation  began  at  the  end  of  six 
weeks.  In  about  one-third  of  the  recorded  cases  both  glands 
have  been  aftected,  the  involvement  of  one  preceding  that  of 
the  other  by  two  or  three  days,  as  a  rule. 


8o  ABDOMINAL   OPER.\TIONS. 

The  causes  of  secondar}^  parotitis  remained  long  obscure. 
It  was  at  first  regarded  merely  as  a  A^ariety  of  mumps,  or  primary 
parotitis,  until  experience  shewed  that  there  were  two  very 
marked  differences  between  them, — primar}^  parotitis  being  an 
infectious  and  non-suppurative  disease,  secondar}^  parotitis 
being  non-infectious  and  prone  to  suppurate.  Three  chief 
theories  have  been  held  with  regard  to  the  nature  of  this  disease. 

For  able  discussions  of  this  subject  see  Dyball,  "Annals  of 
Surgery,"  vol.  xl,  p.  886,  and  Rupert  Bucknall,  "Lancet,"  vol. 
ii,  1905,  p.  1 1 58,  to  both  of  whom  I  am  indebted  for  some  of 
the  following  particulars : 

I.  The  PycBmic  or  Embolic  Theory. — This  was  the  first  of 
the  theories  to  receive  general  approval.  It  was  universally 
recognized  at  one  time  that  secondar>^  parotitis  occurred  in  as- 
sociation with  operations  where  suppuration  took  place,  and  it 
was  not  unnaturally  supposed  that  the  incidence  of  this  phe- 
nomenon was  due  to  septic  embolism  of  the  parotid  vessels,  the 
infected  clots  being  derived  from  the  neighbourhood  of  the 
suppurating  wound.  But  the  objections  to  this  view  were  soon 
recognised  to  be  two, — secondary  parotitis  was  known  to  follow 
operations  where  no  obvious  infection  had  occurred,  when  no 
evidence  of  thrombosis  was  present;  and  in  fatal  cases,  even 
when  there  had  been  suppuration  in  the  original  wound,  there 
was  sometimes  no  sign  of  venous  thrombosis,  and  no  discoverable 
source  there,  or  elsewhere,  of  septic  emboli. 

Undoubted  instances  of  pyemic  infection  of  the  parotid  gland 
have  occurred,  but  the  glandular  infection  has  only  developed 
at  a  late  stage  of  the  disease  and  long  after  other  parts  have 
suffered. 

The  known  facts,  therefore,  with  regard  to  secondary  paro- 
titis were  that  it  occurred  apart  from  other  pyaemic  manifesta- 
tions in  the  great  majority  of  cases ;  that,  in  fatal  cases,  no  source 
of  infected  emboli  could  be  discovered;  that  in  cases  where 
metastasis  undoubtedly  occurred  other  parts  than  the  parotid 


THE   COMPLICATIONS   AND    SEQUELS.  8 1 

were  affected,  and  were  affected  at  an  earlier  stage.     Bucknall 
writes : 

' '  More  recently  the  question  of  embolic  origin  has  been  def- 
initely proved  to  be  incorrect,  for  it  has  been  shown  by  micro- 
scopic examination  that  the  conditions  present  are  different 
in  secondary  parotitis,  and  in  parotitis  of  pysemic  origin.  In 
the  former  instance  the  process  of  inflammation  begins  around 
the  ducts  in  the  centres  of  the  lobules,  and,  moreover,  many 


Vii<g>jT|3 


-■viT 


-^-JSES.-,.iSi^-**'" 


Fig.  14. — Parotitis,  early  stage.  Vessels  normal;  small  duct  blocked  with 
debris;  walls  breaking  down;  tissue  around  inflamed  and  infiltrated  with  small 
round  cells;  large  duct  blocked  with  debris,  containing  organisms  to  high 
power;  blood-vessel  unaffected  (Rupert  Bucknall). 

lobules  are  simultaneously  affected.  In  the  latter  the  inflamma- 
tion begins  around  the  arteries  which  run  in  the  perilobular 
tissue  and  the  inflamed  mass  is  a  single  one,  involving  the  area 
of  gland-tissue  supplied  by  the  particular  vessel  which  has 
become  blocked  with  septic  clot.  " 

2.  The  Sympathetic  or  Reflex  Theory. — This  theory  owes  its 
origin,  or  at  least  its  chief  advocacy,  to  Stephen  Paget.  It 
rests  upon  a  supposed  sympathy  existing  between  the  parotid 


82 


ABDOMINAL   OPERATIONS 


glands  and  the  generative  organs,  and  in  support  of  it  is  quoted 
the  known  relationship  existing  between  mumps  and  orchitis 
or  ovaritis.  Such  a  view^  as  this,  however,  is  not  in  accordance 
with  modem  pathological  views.  A  closer  investigation  of  the 
so-called  "sympathetic"  affections  shews  that  it  is  infection, 
and  infection  alone,  which  is  the  cause  of  the  acute  inflamma- 
tory manifestations.  The  appearance  of  a  theory  such  as  this 
was    perhaps  not  surprising  at  a  time  when,   as   I  have    said, 


Fig.  15. — Parotitis,  more  advanced.      Infected  ducts  and  adjacent  central  parts 
of  lobule  breaking  down  to  form  abscess  cavities   (Rupert  Bucknall). 


almost  all  abdominal  operators  were  concerned  with  the  genera- 
tive organs  of  the  female. 

3.  The  Duct-infection  Theory. — The  suggestion  that  secondary 
inflammation  of  the  parotid  was  due  to  direct  infection  of  the 
gland  by  the  invasion  of  the  duct  by  organisms  from  the  mouth 
was  made  by  Hanau  and  Pilliet  in  1889.  So  good  an  account 
of  this  view  is  given  by  Bucknall  that  I  take  the  liberty  of 
quoting  it  in  full: 


THE    COMPLICATIONS    AND    SEQUELS. 


83 


They  found  on  microscopical  examination  of  sections  of  the 
parotid  (i)  that  the  ducts  were  choked  with  debris  containing 
micro-organisms;  and  (2)  that  the  inflammatory  processes  pres- 
ent invariably  began  around  the  ducts  in  the  centre  of  each 
lobule  and  only  spread  later  to  the  periphery  of  the  lobule  and 
the  perilobular  connective  tissue  in  which  the  blood-vessels  are 
situated.  They  concluded,  therefore,  that  secondary'  parotitis 
could  not  be  of  embolic  origin,  or  else  the  inflammation  would 


Fig.  16. — Parotitis,  late  stage.  Gland  tissue  destroyed  and  replaced  by  in- 
flammatory products,  which  are  breaking  down  to  form  abscess  cavities;  vessels 
not  thrombosed  or  specially  inflamed  (Rupert  Bucknall). 


have  originated  around  the  vessels,  and  that  the  fact  that  in- 
flammation began  simultaneously  in  the  centres  of  many  lob- 
ules at  once,  pointed  to  an  ascending  infection  of  the  ducts 
as  the  real  source  of  the  affection, — a  conclusion  which  was 
further  borne  out  by  the  actual  presence  of  micro-organisms  in 
the  ducts  themselves  in  such  cases. 

Additional  evidence  of  dift'erent  kinds  has  been  subsequently 
brought  forward  in  support  of  this  view. 


84  ABDOMINAL   OPERATIONS. 

(i)  Microscopic  sections  serve  to  show  that  in  all  cases  of 
secondary  parotitis  the  disease  pursues  the  following  course :  (a) 
The  ducts  become  blocked  with  debris  containing  micro-organ- 
isms, (b)  Inflammation  first  begins  in  the  centre  of  each  lobule 
around  the  ducts,  and  at  a  point  farthest  away  from  the  vessels. 
(c)  Many  lobules  are  simultaneously  affected;  they  each  be- 
come centralty  necrosed  and  then,  finally,  by  extension  they  fuse 
to  form  a  multilocular  abscess  cavitv. 


Fig.  17. — Parotitis,  late  stage.      Shewing  multilocular  abscesses  in  sites  of  ducts, 
and  general  small-cell  infiltration  of  lobules  (Rupert  Bucknall). 

(2)  Bacteriological  examination,  first  carried  out  by  Girode, 
has  served  to  prove:  (a)  That  several  different  kinds  of  or- 
ganisms may  give  rise  to  secondary  parotitis,  the  commonest 
being  the  staphylococcus,  the  next  frequent  the  pneumococcus, 
and  after  that  the  pneumobacillus,  the  typhoid  bacillus,  the  colon 
bacillus,  and  the  streptococcus,  in  order  of  frequency.  (6) 
That  on  taking  cultivations  from  the  gland  itself,  the  pus  con- 
tained in  it,  the  orifice  of  Stenson's  duct,  and  the  oral  cavity 
respectively,  the  organisms  found  at  each  spot  are  invariably 


THE    COMPLICATIONS   AND    SEQUELS.  85 

identical  in  each  individual  case,  a  fact  which  supports  the  con- 
clusion that  the  infection  of  the  gland  spreads  from  the  mouth 
via  the  duct,  (c)  That  the  organism  giving  rise  to  secondary 
parotitis  is  by  no  means  invariably  the  same  as  that  giving 
rise  to  the  primary  disease  during  the  course  of  which  the 
attack  of  parotitis  has  arisen.  Thus,  in  the  cases  complicating 
pneumonia  the  organism  causing  parotitis  may  be  the  pneu- 
mococcus  or  the  staphylococcus ;  in  typhoid  fever  it  may  occa- 
sionally be  the  typhoid  bacillus,  but  it  is  much  more  com- 
monly the  staphylococcus  or  pneumococcus.  In  embolic  par- 
otitis due  to  pyaemia,  on  the  other  hand,  the  organism  in  the 
parotid  is  invariably  identical  with  that  giving  rise  to  the  pri- 
mary disease  and  the  abscesses  in  other  parts  of  the  body. 

Microscopical  or  bacteriological  evidence  of  direct  or  ascend- 
ing infection  has  been  brought  forward  by  the  following  ob- 
servers: Girode  (12  cases),  Prantois  (2  cases),  Diaz,  Swain, 
Bosquier,  Morley,  and  Subkovski.  Toupet,  Testa,  Subkovski 
and  Fischel  found  the  pneumococcus  in  the  gland  in  cases  of 
lobar  pneumonia,  and  Janowski  and  Lehmann  found  the  ty- 
phoid bacillus  in  cases  of  enteric  fever.  Girode,  on  the  other 
hand,  found  the  staphylococcus  to  be  the  cause  of  the  parotid 
infection  in  a  case  of  pneumococcus  pneumonia,  and  the 
pneumobacillus  to  be  present  in  the  gland  in  a  case  of 
puerperal  septicemia  of  streptococcus  origin.  Various  observ- 
ers, moreover,  have  shown  that  parotitis  complicating  enteric 
fever  is  far  more  frequently  due  to  the  staphylococcus  than 
the  typhoid  bacillus. 

Post-operative  Haematemesis. — Hsematemesis  which  follows 
upon  operations  upon  the  stomach,  and  is  obviously  due 
to  the  improper  or  imperfect  application  of  sutures  in  the 
formation  of  an  anastomosis  between  the  stomach  and  the 
duodenum  and  jejunum,  is  not  considered  in  the  following 
remarks. 

Post-operative  hasmatemesis  follows  far  more  frequently 
upon     operations     involving     the     opening    of     the     abdomen 


86  ABDOMINAL    OPER-\TIOXS. 

than  upon  any  other  operations.  It  is  true  that  cases 
of  even  fatal  hgematemesis  have  occurred  after  operations 
upon  the  bladder  or  urethra,  upon  the  head,  and  upon 
the  extremities;  but  all  these  cases  together  do  not,  in 
number,  form  a  tithe  of  those  which  are  seen  after  abdom- 
inal operations. 

In  the  majority  of  instances  heematemesis  begins  within 
twenty-four  hours  of  the  operation.  The  blood  which  is 
vomited  has  always  been  in  the  stomach  a  sufficient  length 
of  time  to  become  partly  digested,  the  result  being  that  the 
vomit  is  always  black.  "Black  vomit"  is  the  name  by 
which  the  condition  is  chiefly  known  by  nurses.  The  pa- 
tient may  or  may  not  have  suffered  from  ether  or  chloro- 
form sickness;  but,  whether  he  has  or  not,  there  is  usually 
an  inter^-al  between  the  cessation  of  this  and  the  com- 
mencement of  the  hsematemesis.  As  a  rule,  the  amount 
vomited  is  small;  there  are  rarely  more  than  two  to  five 
ounces  at  a  time.  The  characteristic  condition  is  for  an 
ounce  or  two  to  be  vomited  at  frequent  intervals.  The 
vomit  is  often  intensely  acid,  and  bums  the  patient's  mouth, 
throat,  and  lips.  In  many  cases  a  broad,  red  mark  on 
the  chin  or  cheek  will  shew  where  the  vomited  fluid  has 
run  down  to  the  basin,  and  the  lips  often  become  swollen, 
red,  and  very  tender,  for  the  patient  makes  little  or  no 
effort  to  expel  the  fluid,  allowing  it  to  trickle  away  from 
his   mouth. 

The  general  condition  of  the  patient  is  always  bad. 
The  aspect  indicates  a  condition  of  profound  depression. 
The  pulse  is  small  and  rapid,  the  skin  cold  and  moist, 
the  limbs  clammy  with  sweat.  The  temperature  is  often 
subnormal.  There  is,  as  a  rule,  a  rapidly  progressive  col- 
lapse. Indeed,  in  the  severest  cases  one  cannot  but  feel 
that  the  patient  is  the  victim  of  a  profound  toxaemia — 
that  a  poison  of  unusual  virulence  is  killing  him.  Patients 
are   often   curiously   sensitive   to   all  impressions   in   the   early 


THE   COMPLICATIONS   AND    SEQUELS.  87 

Stage — their  mental  alertness  is  remarkable,  but  their  com- 
ments soon  become  spasmodic  and  jerky,  and  mal  a  propos, 
and   lethargy,  dulness,    and  general  inertia  rapidly  follow. 

In  a  very  large  number  of  the  recorded  cases  a  fatal 
issue  has  occurred.  In  a  series  of  twenty-nine  cases  re- 
ferred to  by  Purves  ("  Edin.  Med.  Jour.,"  March,  1902)  the 
death-rate  was  equivalent  to  69  per  cent.,  and  this  estimate 
is  approximately  that  which  is  given  by  the  majority  of 
writers,  though  from  my  own  experience  I  believe  it  to 
be  a  gross  exaggeration.  Heematemesis  follows  upon  any 
abdominal  operation,  but  is  more  especially  to  be  looked 
for  when  the  stomach,  duodenum,  or  bile-passages  are 
the  seat  of  disease.  The  time  of  onset,  though  usually 
within  the  first  forty-eight  hours,  may  be  delayed  for  as 
long  as  ten  days. 

The  cause  of  the  h^matemesis  is  not  definitely  known. 
A  great  variety  of  theories  have  been  suggested.  Among 
them  are  the  following: 

Firstly. — It  has  been  suggested  that  the  anesthetic  is 
the  cause  of  the  bleeding.  It  is,  however,  an  undoubted 
fact  that  precisely  the  same  symptom  may  be  observed 
when   the   operation   has   been   performed   under   cocaine. 

Secondly. — Distinct  injury  to  the  stomach  or  duodenum 
is  said  to  result  in  ulceration,  from  which  the  blood  comes. 
In  some  cases  an  ulcer  or  several  ulcers  have  been  found 
on  postmortem  examination.  It  is  suggested  that  the 
damage  done  to  the  stomach  produces  a  local  necrosis, 
and  that  the  gastric  juice  then  digests  the  slough,  and  an 
ulcer  results.  Kronlein,  however,  has  shewn  that,  in  order 
to  produce  ulcers  ■  in  this  manner,  several  days  must  elapse 
between  the  time  of  the  receipt  of  the  injury  and  the 
time  when  an  ulcer  is  found.  Though  this  explanation 
may  be  acceptable  for  some  cases,  it  cannot,  therefore, 
apply  to  them  all. 

Thirdly. — The    suggestion    put    forth    by    von    Eiselsberg — 


88  ABDOMINAL   OPERATIONS. 

who,  in  1899,  first  drew  prominent  attention  to  this  symp- 
tom— was  that  injury  to  the  omentum  was  the  immediate 
cause.  Rough  handhng  or  twisting  or  Hgation  of  the 
omentum  produced  a  thrombosis  of  the  omental  vessels 
followed  by  embolism  in  the  wall  of  the  stomach,  and 
in  consequence  ulceration  of  the  stomach  resulted.  Purves 
writes  on  this  point: 

"In  reference  to  the  stomach,  in  particular,  von  Eisels- 
berg  considers  that,  after  ligature  of  the  omental  branch 
of  the  epiploic  artery,  the  vessel  becomes  thrombosed  and 
the  thrombus  extends  back  to  the  origin  of  the  vessel. 
The  vessels  lie  at  right  angles  to  one  another,  and  he 
conceives  that  a  portion  of  the  thrombus  projecting  into 
the  epiploic  may  be  swept  off  into  the  passing  stream  and 
carried  on  into  some  of  the  branches  going  to  the  stomach- 
wall,  there  to  form  a  thrombus  and  ultimately  a  digestive 
ulcer.  He  considers  that  this  is  the  most  prominent  etio- 
logical factor  in  the  production  of  post-operative  hasmat- 
emesis." 

The  suggestion  is  one  which,  doubtless,  contains  some 
measure  of  truth,  but  it  is  not,  of  course,  applicable  to 
all  cases. 

Fourthly. — W.  L.  Rodman  has  suggested  that  sepsis  is 
the  chief  cause.  This  seems  to  me  to  be  the  most  likely 
of  all  the  explanations  that  have  been  given,  though  it 
cannot  be  denied  that  in  some  instances  the  obvious  evi- 
dences of  sepsis  elsewhere  are  wanting.  In  some  of  these 
cases  it  may  be  that  the  sepsis  is  of  such  a  character 
as  to  produce  a  rapidly  fatal  toxemia,  the  poison  acting 
so  rapidly,  indeed,  that  local  evidences — peritonitis,  etc. — 
have  no  time  to  develop. 

In  this  connexion  recent  inquiries  conducted  at  the  London 
Hospital  are  of  the  greatest  interest.  They  shew  more  clearly 
than  any  other  pathological  records  of  which  I  have  knowledge 
how  dependent  a  severe  hsematemesis  may  be  upon  lesions  which 


THE   COMPLICATIONS   AND    SEQUELS.  89 

are  primarily  unconnected  with  the  stomach.  Hutchinson  records 
24  cases  of  fatal  haemorrhage  from  the  stomach  after  opera- 
tions of  various  kinds  upon  the  abdominal  viscera.  Of  these  24 
no  less  than  21  were  cases  of  appendicitis  with  septic  complica- 
tions, localised  abscess,  or  diffuse  peritonitis.  In  three  cases  re- 
cent acute  ulcers  were  found  in  the  stomach  (twice)  and  in  the 
duodenum  (once) ;  in  the  remaining  cases  only  ' '  hemorrhagic 
erosions"  were  found.  The  origin  of  this  serious  and  profuse 
bleeding  is  ascribed  to  a  profound  alteration  in  the  blood  due  in 
most  cases  to  toxins  of  septic  origin.  The  experiments  of  Wilkie 
would  make  it  appear  probable  that  a  retrograde  venous  embolism 
from  the  original  septic  focus  may  be  responsible  for  the  develop- 
ment of  acute  ulceration  in  the  stomach  or  duodenum. 

Fifthly. — Mayo  Robson,  disputing  the  theory  suggested 
by  Rodman,  writes:  "The  only  explanation  that  seems  at 
all  feasible  is  that  the  haemorrhage  is  dependent  on  a  reflex 
nervous  influence."  The  apt  comment  of  Purves  on  this 
statement  is:  "This  is  no  more  easy  to  prove  than  the 
other  suggestions ;  but,  if  it  were  a  true  solution  of  the 
question,  it  is,  I  think,  admissible  to  suppose  that  sepsis 
would,  in  many  cases,  determine  the  onset  of  the  reflex 
or  prolong  the  duration  of  its  action,  and  thus  render 
the  condition  more  serious." 

The  treatment  of  hsematemesis  will  depend  in  part 
upon  the  condition  of  the  patient.  In  those  whose  con- 
dition is  fairly  good,  lavage  of  the  stomach  with  a  tepid 
solution  of  bicarbonate  of  soda  will  generally  arrest  the 
sickness  and  give  relief.  The  bow^els  should  be  compelled, 
if  possible,  to  act  freely;  high  enemata  of  soap  and  water 
or  oil  must  be  given.  Sips  of  water  containing  adrenalin 
chloride  solution — ten  minims  to  a  teaspoonful — should  be 
given  every  half -hour;  the  general  and  the  local  eft'ect  of  this 
drug  are  both  desirable.  Calomel  may  be  given  in  doses 
of  one-half  grain  every  half-hour. 


90  ABDOMINAL   OPERATIONS. 

The  abdominal  bandage  should  be  applied  firmly — as 
firmly,  indeed,  as  the  patient  can  bear  it. 

If  the  symptoms  of  toxcemia  are  well  marked,  an  intra- 
venous infusion  of  saline  solution  will  prove  of  value. 

Reichard  has  reopened  the  abdomen  in  two  cases  for 
the  purpose  of  searching  for  the  source  of  the  haemorrhage 
in    the    stomach.      This    is    a    futile    and   useless    procedure. 

Acute  Dilatation  of  the  Stomach. — This  is  among  the  least 
frequent  but  most  serious  complications  Avhich  may  follow 
upon  an  abdominal  operation.  A  large  number  of  cases  have 
now  been  reported,  and  an  excellent  review  of  many  of  them 
published  by  Campbell  Thomson  ("Acute  Dilatation  of  the  Stom- 
ach;" Bailliere,  Tindall  &  Cox,  London,  1902). 

Symptoms. — The  symptoms  appear  as  a  rule  rather  insid- 
iously after  an  abdominal  operation.  The  chief  of  them  are  pain 
in  the  epigastrium,  constant,  effortless  vomiting  of  a  thin  greenish 
or  greyish  turbid  fluid,  a  rapid  and  steadily  increasing  pulse-rate, 
and  s3^mptoms  of  collapse  or  exhaustion.  The  act  of  vomiting 
is  not  often  distressing  though  its  frequent  repetition  may  be 
exhausting.  As  Henr}^  ]\Iorris  remarked  of  one  of  his  cases,  the 
vomit  is  brought  up  "in  large  gulps  without  straining."  The 
surgeon's  attention  should  be  drawn  to  this  complication  by 
the  repeated  vomiting  and  the  constantly  increasing  pulse-rate. 
An  examination  of  the  abdomen  will  then  reveal  a  tight  dis- 
tension of  the  epigastrium,  and  when  the  bandages  are  removed, 
the  outline  of  the  grossly  inflated  stomach  may  be  marked. 
The  passage  of  the  stomach  tube  allows  a  huge  volume  of  gas 
to  escape,  often  with  a  miniature  "report,"  and  a  large  A'olume 
of  thin  greyish  fluid  will  be  evacuated.  As  soon  as  the  tube  is 
withdrawn,  the  stomach  may  begin  almost  at  once  to  refill,  and 
within  half  an  hour  its  distended  form  may  be  recognised  upon 
inspection  of  the  abdomen.  AVhen  the  stomach  distension 
becomes,  as  it  may,  gigantic,  the  bulging  of  the  abdominal 
wall  is  mostly  to  the  left  and  in  the  lower  half ;  the  right  hypochon- 
drium  by  contrast  has  been  said  to  be  flattened  or  excavated. 


THE   COMPLICATIONS   AND    SEQUELS.  9I 

In  other  cases,  though  the  abdomen  is  large,  tense,  and  resisting, 
no  special  bulging  at  any  point  can  be  seen,  while  in  yet  others 
the  abdomen  may  be,  as  in  Henry  Morris's  case,  retracted.  In 
this  instance,  at  the  postmortem  examination,  although  the 
stomach  was  enormously  dilated  and  occupied  the  greater  part 
of  the  abdomen,  its  anterior  surface  was  said  to  be  flattened. 

The  general  condition  of  the  patient  is  recognised  as  being 
serious  from  the  first.     The  respirations  are  frequent  and  shallow ; 


Fig.    18. — Acute  dilatation  of  the  stomach  (Campbell  Thomson). 

the  pulse  is  rapid,  thready,  and  of  poor  quality ;  the  aspect  of  the 
patient  shows  that  his  tissues  are  starved  of  water ;  he  is  pinched 
and  careworn  and  old  in  appearance,  and  the  limbs  are  often  cold 
and  clammy.  Thirst  is  intolerable  and  unquenchable;  the  pa- 
tient is  restless,  and  at  times  irritable  and  weary.  Diarrhoea  has 
been  occasionally  observed.  The  amount  of  urine  in  nearly 
every  instance  in  which  special  attention  has  been  given  to  the 
point  has  been  very  considerably  reduced  in  cjuantity,  or  the 
secretion  entirely  abolished. 


92  ABDOMINAL   OPEIL\TIONS. 

Pathology. — The  appearances  presented  on  postmortem  ex- 
amination are  curiously  similar  in  almost  all  cases.  The  stomach 
is  enormously  distended,  and  is  sharply  bent  upon  itself,  so  as 
to  form  a  gigantic  U-tube,  whose  distal  limb  is  rather  shorter 
and  less  thick  than  the  proximal.  At  the  lesser  curvature  there 
is  therefore  a  sharp  kink.  The  stomach  seems  to  occupy  the 
greater  part  or  even  the  whole  of  the  abdomen,  cutting  off  from 
sight  and  severely  compressing  all  the  small  and  large  intestine. 
The  walls  of  the  stomach  are  tightly  stretched  and  thinned,  in 
one  case  seeming  no  thicker  than  a  single  layer  of  peritoneum. 
The  thinning  of  the  walls  is  not  equally  distributed;  very  thin 
patches  are  sometimes  seen,  the  greater  part  of  the  stom- 
ach remaining  normal,  or  nearly  so.  In  12  cases  out  of  44, 
the  dilatation  was  not  limited  to  the  stomach,  but  involved 
the  duodenum  also,  and  in  one  case  the  upper  few  inches  of 
the  jejunum.  Box  and  A¥allace  have  shown  that  the  con- 
dition found  in  acute  dilatation  of  the  stomach  can  be  exactly 
reproduced  on  the  cadaver.     They  write : 

' '  We  have  found  by  actual  experiment  on  the  cadaver  that 
the  stomach  can  be  enormously  distended  by  water  pressure, 
with  the  jejunum  cut  right  across  and  lying  patent  in  the 
abdomen.  Moreover,  the  stomach  remains  thus  distended. 
The  same  result  can  be  attained  after  the  superior  mesenteric 
vessels  and  the  peritoneal  folds  in  their  neighbourhood  ha^'e  all 
been  divided.  If,  however,  by  introduction  of  the  finger  well 
behind  the  distended  stomach  a  little  to  the  left  of  the  mid-line 
of  the  spinal  column,  the  fundus  and  posterior  wall  of  the 
stomach  be  gently  raised,  the  excess  of  fluid  will  at  once  flow 
freely  away  from  the  stomach  through  the  cut  jejunum.  If  the 
part  of  the  duodenum  which  lies  on  the  right  side  of  the  spine, 
behind  the  peritoneum,  be  first  incised,  the  tense  distension  of 
the  stomach  cannot  be  produced.  We  therefore  feel  justified 
in  assuming  that  the  tense  distension  is  due  to  actual  pressure 
of  the  stomach  on  the  part  of  the  duodenum  which  crosses  the 
third  and  ascends  Iw  the  side  of  the  second  lumbar  vertebra  to 
end  in  the  jejunum. 

"We  woiild  suggest,  therefore,  that  in  producing  the  train  of 


THE   COMPLICATIONS   AND    SEQUPXS.  93 

symptoms  miet  with  in  acute  dilatation  of  the  stomach  two 
factors  come  into  play.  There  is,  first,  a  paralytic  condition 
of  the  viscus  which  leads  to  distension,  and  then,  at  a  certain 
stage,  the  distended  stomach  actually  produces  obstruction  by 
pressing  on  the  duodenum  on  the  front  and  to  the  left  of  the 
spinal  column."      ("The  Lancet,"  November  9,  1901,  p.  1260.) 

A  large  number  of  more  or  less  ingenious  hypotheses  have 
been  suggested  to  explain  the  incidence  of  acute  gastric  dilata- 
tion, but  none  of  them  are  completely  satisfying. 

By  Fagge  and  others  an  excessive  secretion  of  the  stomach 
was  considered  the  primary  factor,  the  organ  being  "paralysed 
from  overdistension,  and  unable  to  rid  itself  of  its  burden." 
Henry  Morris,  who  considered  the  excess  of  secretion  to  be  an 
important  determining  cause,  suggested  the  name  "gastro- 
succorrhoea"  for  this  disease.  In  several  cases,  however,  the 
distension  of  the  organ  is  not  by  any  means  wholly  or  even 
chiefly  due  to  the  fluid  contents ;  for  when  the  stomach  is  emp- 
tied of  gas  by  a  stomach  tube,  and  before  any  fluid  has  escaped, 
the  viscus  may  return  almost  to  its  normal  size.  Campbell 
Thomson  writes : 

"It  is,  of  course,  a  difficult  matter  to  establish  precisely  the 
relationship  which  exists  between  the  distension  and  the  secre- 
tion, but  it  seems  probable  that  they  must  be  looked  upon  as 
two  distinct  processes. 

' '  The  most  likely  explanation  seems  to  be  that  the  stomach 
wall  becomes  paralysed — the  possible  causes  of  which  will  be 
discussed  further  on — and  then,  later  on,  the  organ  becomes 
distended  by  gas  or  excessive  secretion.  Moreover,  the  fact 
that  excessive  secretion  is  not  present  in  every  case  makes  it  im- 
possible to  consider  it  as  the  primary  cause ;  in  some  cases  there 
is  very  little  fluid  found  after  death,  the  stomach  being  almost 
entirely  distended  with  gas." 

Pepper  and  Stengel  suggest  that  the  immediate  cause  of 
the  dilatation  is  a  spasm  of  the  pylorus;  but  if  this  were  so, 
the  not  infrequent  implication  of  the  duodenum  would  be  still 


94  ABDOMINAL    OPERATIONS. 

to  explain.  Wiesinger  considers  that  there  is  a  volvulus  of 
the  stomach,  and  that  the  distension  is  similar  to  that  found 
in  a  twisted  sigmoid  flexure. 

Albrecht  was  the  first  to  suggest  that  the  constricting  agent  is 
the  superior  mesenteric  arter\",  which,  owing  to  the  downward 
dragging  of  the  intestines,  presses  upon  and  obstructs  the  third 
portion  of  the  duodenum.  Kundrat,  Ewart,  and  others  have 
offered  evidence  in  support  of  this  view,  and  there  is  little 
doubt  that  in  some  cases,  at  least,  the  explanation  is  satis- 
facton*.  Albrecht  points  out  that  if  the  descending  portion  of 
the  duodenum  be  opened  and  the  finger  passed  onwards  into 
the  transverse  portion,  and  with  the  other  hand  traction  be 
made  upon  the  mesentery  by  pulling  the  intestines  towards 
the  pelvis,  the  constricting  power  of  the  superior  mesen- 
teric arter}'  will  be  clearly  recognised.  In  Jessop's  case, 
and  in  others,  the  distended  duodenum  was  abruptly  narrowed 
at  or  near  the  point  of  crossing  of  the  arten^ ;  but  in  other  cases, 
and  these  form  a  majority,  there  was  no  constant  point  at  which 
the  stricture  was  found. 

T.  Ordway  ("Bost.  Aled.  and  Surg.  Joum.,"  Alarch  5,  1908) 
writes  as  follows  describing  the  post-mortem  report  upon  a  case 
of  acute  dilatation  in  a  moribund  phthisical  patient:  "The  mes- 
enteric attachment  which  crosses  the  last  part  of  the  duodenum 
is  tense.  It  presses  the  duodenum  against  the  spinal  column 
and  this  produces  complete  obstruction.  Above  this  obstruc- 
tion the  duodenum  is  markedty  dilated  and  continuous  with  the 
stomach.  Below  this  point  both  small  and  large  intestines  are 
coUapsed  and  apparently  empty." 

An  interesting  point  in  connexion  with  the  clinical  history 
of  this  case  is  that  although  the  vomit  frequently  amounted  to 
two  quarts  within  ten  or  fifteen  minutes,  there  was  no  abdominal 
distension;  on  the  other  hand,  there  was  marked  retraction  and 
muscular  rigidity. 

The  view  which  seems  to  be  most  highly  favoured  by  the 
majority  of  writers  is  that  the  paralysis  of  the  muscular   wall 


THE   COMPLICATIONS   AND    SEQUELS.  95 

of  the  stomach  is  primary.  Carrion  and  Hallon  ("Semaine 
Medicale,"  August  21,  1895)  have  shown  that  the  section  of  the 
pneumogastric  nerves  in  the  dog  leads  to  dilatation  of  the 
stomach,  and  to  symptoms  resembling  in  many  cases  those  of 
uraemia.  It  is  clear  that  in  some  instances,  as  soon  as  the  stom- 
ach has  reached  a  certain  size,  it  is  almost  impossible  for  it  to 
recover,  either  because  there  is  some  kinking  or  rotation  at  the 
pylorus,  or  because  pressure  is  exerted,  as  Box  and  Wallace 
suggest,  upon  that  part  of  the  duodenum  which  crosses  the 
third  and  ascends  by  the  side  of  the  second  lumbar  vertebra  in 
the  left  side. 

Attention  has  been  specially  drawn  by  P.  Miiller  ("Deut. 
Zeit.  f.  Chir.,"  August,  1900)  to  dilatation  of  the  stomach  following 
upon  abdominal  operations.  In  some  of  these  cases  the  gastric 
distension  is  only  a  part  of  a  general  involvement  of  the  intestinal 
canal,  due  to  peritonitis.  The  septic  condition  induces  a  paresis 
of  the  bowel  walls,  and  distension  of  the  gut  rapidly  follows. 
In  other  cases,  and  it  is  these  to  which  Miiller  draws  particular 
attention,  the  dilatation  of  the  stomach  is  due  to  the  pressure 
upon  the  duodenum  of  the  superior  mesenteric  artery.  When  a 
large  ovarian  tumour  or  a  fibroid  tumour  of  the  uterus  is  re- 
moved, the  intestines,  compressed  for  many  months  or  years  to 
the  upper  part  of  the  abdomen,  sink  down  into  the  pelvis,  and  so 
drag  upon  the  superior  mesenteric  artery  as  to  compress  the 
duodenum  in  the  manner  already  described. 

L.  A.  Conner  ("Medical  Record,"  i,  1907),  who  has  analysed 
102  cases  of  acute  dilatation,  concludes  that  the  condition  oc- 
curs most  frequently  after  operation  under  general  anaesthesia,  and 
is  usually  associated  with  a  constriction  at  the  lower  end  of  the 
duodenum,  between  the  root  of  the  mesentery  and  the  vertebral 
column.  That  this  constriction  can  be  brought  about  when  trac- 
tion is  made  on  the  mesentery  by  the  small  intestines  hanging 
over  the  brim  of  the  pelvis ;  that  it  is  favoured  by  the  dorsal  posi- 
tion, a  long  mesentery,  and  a  collapsed  state  of  the  gut.  He  gives 
the  mortality  as  72  per  cent. 


96  ABDOMINAL   OPERATIONS. 

Treatment. — Treatment  should  be  directed,  early  to  the  relief 
of  this  condition.  Indeed,  if  the  case  progresses  far  without 
recognition,  the  issue  is  almost  inevitably  fatal.  Recourse  must 
be  had  at  once  to  the  stomach  tube,  and  the  viscus  must  be  emp- 
tied and  washed  out  with  an  abundance  of  hot  sterile  salt  solu- 
tion. If,  as  is  likely,  the  stomach  begins  quickly  to  refill,  the 
tube  must  be  again  passed,  and  if  necessary  be  left  in  for 
several  hours. 

In  my  own  few  cases,  relief  has  always  been  given  by  changing 
the  position  of  the  patient.  He  must  be  placed  prone  in  bed, 
with  a  pillow  beneath  the  pelvis.  One  acts  upon  the  supposition 
that  there  is  compression  of  the  duodenum  by  mechanical  traction 
upon  the  superior  mesenteric  vessels.  Whether  the  hypothesis 
be  right  or  wrong,  relief  is  undoubtedly  afforded,  sometimes 
in  a  most  remarkable  manner,  by  the  change  of  posture.  In 
the  severer  instances  opening  and  drainage  of  the  stomach  may 
be  necessary;  or  the  operation  of  gastro-enterostomy  may  be 
considered. 

Phlebitis  and  Thrombosis. — The  occurrence  of  thrombosis 
of  veins  is  not  very  infrequent  after  any  form  of  abdominal 
operation.  It  follows  most  commonly  upon  pelvic  operations, 
especially  abdominal  hysterectomy,  but  also  after  operations 
involving  the  upper  part  of  the  abdomen,  such  as  gastro-enteros- 
tomy or  cholecystotomy. 

The  thrombosis  of  the  vein  may  be  due  to  or  may  precede 
phlebitis.  If  thrombosis  is  the  primary  condition,  which  is 
probably  very  unusual,  it  is  attributed  to  heart  weakness,  and 
consequent  slowness  of  the  blood  current,  impoverished  con- 
dition of  the  blood  as  a  result  of  long  illness,  or  repeated  haemor- 
rhages (the  "marasmic  thrombosis"  of  Billroth),  and  to  an  in- 
crease in  the  coagulability  of  the  blood  due  to  an  excess  of  calcium 
salts. 

In  the  very  great  majority  of  the  cases,  however,  it  is  probable 
that  phlebitis  occurs  first,  and  that  the  formation  of  a  thrombus 
is   secondary.     The   phlebitis   is   due,    almost   certainly,    to   in- 


THE   COMPLICATIONS    AND    SEQUELS.  97 

fection,  though  many  of  the  recorded  examples  occurred  when 
it  is  said  that  the  wound  remained  aseptic. 

A  thrombophlebitis  is  dependent  upon  the  quantity  and  qual- 
ity of  the  circulating  blood  and  the  condition  of  the  vascular 
endothelium.  For  coagulation  to  take  place  there  must  be  fibrin- 
ogen and  fibrin  ferment.  Fibrin  ferment  does  not  exist  normally 
in  circulating  blood  as  such,  but  results  from  a  combination  of 
thrombogen  and  thrombokinase  in  the  presence  of  calcium  salts. 
Thrombokinase  is  probably  produced  from  the  breaking  down  of 
the  blood-platelets  or  of  the  white  blood-corpuscles.  Under 
normal  circumstances  the  vascular  endothelium  appears  to  be 
able  to  deal  with  small  quantities  of  thrombokinase,  but  its  abil- 
ity to  do  so  is  diminished  by  injury  to,  or  inflammation  of,  the 
blood-vessels,  retardation  of  the  blood  current,  sepsis,  increase  in 
COo  in  the  blood,  by  general  conditions,  such  as  chlorosis  and  the 
other  anaemias,  where  the  vascular  nutrition  is  poor,  and  by  the 
specific  fevers. 

The  etiology  of  thrombophlebitis  is  still  as  obscure  as  it  was 
twenty  years  ago. 

Clinically,  thrombosis  may  occur  in  cases  of  acute  or  chronic 
inflammation  of  the  vascular  endothelium  after  trauma,  in  con- 
ditions where  there  is  marked  slowing  of  the  blood  stream,  in 
cases  of  cardiac  weakness,  in  the  ansemias,  or  following  infec- 
tion. 

This  complication  is  found  most  frequently  after  abdominal 
hysterectomy  (30  per  cent,  of  the  cases).  This  is  an  operation 
in  which  there  are  many  ligatures  left  behind,  a  septic  cavity 
is  opened,  and  no  drainage  is  provided.  During  an  interval 
operation  for  appendicitis,  there  may  be  disturbance  of  those 
veins  in  the  mesoappendix  in  which  clots  have  already  formed 
in  the  earlier  stages  of  the  disease.  We  know  now  that  many 
of  the  wounds  which  run  an  "aseptic"  course  really  contain 
organisms  throughout  the  time  of  their  healing.  Infection, 
therefore,  as  a  cause  of  phlebitis,  cannot  be  excluded.  To  me 
it  is  the  most  likely  explanation  in  all  cases,  though  I  quite  rec- 


98  ABDOMINAL   OPERATIONS. 

ognise  that  a  contran^  opinion  to  this  is  held  by  surgeons  of  con- 
siderable authorit}',  such  as  Maurice  Richardson  and  others. 

The  veins  most  frequently  affected  are  the  saphenous  and 
femoral  of  the  left  side.  The  enormous  preponderance  of  the 
cases  on  the  left  side  has  never  been  adequately  explained.  Dr. 
W.  W.  Keen  suggested  that  the  passage  of  the  left  common  iliac 
vein  under  the  right  common  iliac  artery  might  lead  to  a  retarda- 
tion of  the  blood  in  the  left  vein,  and  thus  act  as  a  cause  of 
venous  thrombosis.  This  anatomical  arrangement  doubtless 
plays  some  part  in  the  causation  of  the  condition,  and  it  is  well 
to  note  also  that  when  there  is  any  congenital  anomaly  in  the 
venous  system  below  the  diaphragm,  it  is  almost  invariably 
found  upon  the  left  side.  Varicose  veins  of  the  lower  extrem- 
ity are  far  more  frequent  upon  the  left  side  than  the  right. 
But  it  is  doubtful  whether  the  merely  mechanical  conditions  which 
can  be  brought  about  by  any  of  the  circumstances  mentioned 
would  suffice  to  determine  the  so  frequent  incidence  of  the 
inflammation  upon  the  left  side. 

We  may  summarise  the  main  facts  with  regard  to  thrombosis 
following  abdominal  operations  in  this  way:  Thrombosis  occurs 
most  frequently  after  operations  upon  the  lower  part  of  the  abdo- 
men; it  is  estimated  to  happen  in  2  percent,  of  all  cases;  it  is  first 
noticed  about  two  weeks  after  the  operation ;  it  is  more  apt  to 
afflict  patients  who  are  debilitated  by  long  illness,  or  whose  con- 
dition is  poor  as  a  result  of  frequent  hasmorrhages ;  it  is  found  in 
great  preponderance  upon  the  left  side,  where  it  affects  the 
saphenous  and  femoral  veins;  as  a  causative  factor  sepsis  can 
rarely  be  excluded;   phlebitis  precedes  the  thrombosis,  as  a  rule. 

Cordier  ("Journal  of  the  American  Medical  Association,"  vol. 
ii,  1905,  p.  1792)  has  collected  records  of  232  cases.  He  gives 
the  following  table,  which  shews  the  number  of  cases  following 
various  operations: 

Nephrorrhaphy 9 

Appendicitis,  mostly  so-called  aseptic  cases   27 

Cholecystotomy 4 

Oophorectomy  (cystic,  cirrhotic,  etc.) 16 


THE   COMPLICATIONS  AND   SEQUELS.  99 

Hysterectomy  fibroids,  so-called  aseptic  cases 69 

Vaginal  operations,  character  not  stated 8 

Alexander's  operation 3 

Hernia 4 

Pyosalpinx 7 

Pelvic  operations,  not  specified 9 

Abdominal  and  pelvic,  character  not  stated 56 

Ectopic  pregnancy 4 

Vaginal  hysterectomy  for  cancer 9 

Suspension  of  uterus 7 

.Splenectomy i 

Special  Features. 
In  213  cases,  left  saphenous  or  femoral  veins  were  affected. 
In  8  cases,  both  left  and  right  veins  were  affected. 
In  1 1  cases,  right  veins  alone  were  affected. 
In  182  cases,  proximial  part  of  vein  first  affected. 
In  36  cases,  distal  part  of  vein  first  affected. 
In  14  cases,  portion  of  vein  affected  not  mentioned. 
In  166  cases,  sepsis  was  not  present  at  time  of  the  operation. 
In  56  cases,  no  mention  of  sepsis  or  asepsis  was  made. 
In  10  cases,  there  was  pus  present  at  time  of  operation.      In  the  great 

majority  of  cases  the  first  symptoms  appeared  from  the  loth  to 

the  isth  day. 
In  6  cases,  pleuritic  and  lung  complications. 
In  3  cases,  sudden  death  occurred. 

Cordier  gives  a  good  description  of  the  clinical  course.  He 
writes : 

"The  usual  onset  of  this  condition  is  marked  by  a  gradually 
increasing  pain  along  some  portion  of  the  long  saphenous  vein, 
usually  the  left,  and  most  frequently  just  below  the  saphenous 
opening  in  the  fascia  lata.  This  pain  may  extend  along  the 
whole  course  of  the  vein  and,  as  a  rule,  does  follow  the  vessel  below 
the  knee.  An  elevation  of  temperature  of  from  2  to  3  degrees  is 
noticed  and  a  proportionately  increased  pulse-rate  is  also  ob- 
served. The  pain  in  limb  is  increased  by  moving  the  limb  or 
by  permitting  it  to  remain  in  a  dependent  position,  and  is 
partially  relieved  by  elevating  the  leg  and  thigh.  On  examining, 
in  many  cases,  there  will  be  noticed  a  redness  along  the  course 
of  the  inflamed  vein  or  veins.  If  seen  early,  no  perceptible 
swelling  of  the  limb  will  be  noticed,  but  within  a  few  days,  if 
the  case  is  a  severe  one,  the  whole  limb  will  be  swollen,  but 
more  particularly  the  calf  of  the  leg.  This  swelling  is  uniform, 
and  free  from  discolorations  or  redness;  in  fact,  the  surface  is 
blanched.     Pressure  along  the  course  of  the  vein  elicits  tender- 


100  ABDOMINAL   OPER-\TIOXS. 

ness,  and  in  the  calf  of  the  leg  the  tenderness  is  found  all  over 
the  posterior  surface.  The  vein  is  hardened  and  rolls  under  the 
fingers  like  a  tendon,  in  many  cases.  Pressure,  if  continued  for 
scA'eral  minutes,  may  produce  pitting,  but  not  so  well  marked 
as  in  the  dropsical  affections.  Except  along  the  course  of  the 
superficial  portion  of  the  vein,  which  may  feel  unnaturally 
warm,  there  is  a  death-like  temperature  of  the  surface  to  the 
examining  hand. ' ' 

Grant  f'Jour.  Amer.  Aled.  Assoc,"  1907,  i,  567)  has  pub- 
lished a  report  embodying  the  opinions  of  30  American  surgeons 
with  regard  to  post-operative  thrombosis  in  the  lower  extremi- 
ties. Amongst  the  various  hypotheses  put  for^^ard,  bacterially 
infected  blood,  recumbent  posture,  the  anatomical  situation  of 
the  vein  and  the  quality  of  the  blood  are  said  to  be  the  most  im- 
portant. 

E.  H.  Beckman  ("Annals  of  Surgery,"  1913,  i.  May),  report- 
ing on  the  complications  following  5835  surgical  operations  in  the 
IMayo  Clinic  in  1912,  writes  under  the  head  of  Thrombophlebitis: 
"The  total  number  of  cases  having  a  phlebitis  as  a  complication 
following  operation  was  16.  Although  we  continualty  have  a 
certain  number  of  phlebitis  cases  following  operation,  we  have  not 
been  able  to  determine  any  causative  factor  in  this  annoying 
complication.  We  have  always  taken  a  middle  course,  so  far  as 
getting  the  patients  out  of  bed  early  is  concerned.  Most  laparot- 
omy^ patients  are  kept  in  bed  from  eight  to  twelve  days,  except 
those  having  simple  appendicectomies,  who  are  allowed  to  get 
up  on  the  sixth  or  seventh  day  following  operation.  It  will  be 
seen  from  the  following  table  that  exactly  three-fourths  of  these 
cases  of  phlebitis  were  in  the  left  femoral  or  internal  saphenous 
vein  and  one-fourth  in  the  right.  None  were  double.  This  is 
about  the  usual  proportion  in  our  Clinic. 

It  has  not  been  definitely  determined  that  patients  that  have 
an  infected  wound  or  are  infected  at  the  time  of  the  operation  are 
more  susceptible  to  phlebitis  than  so-called  clean  cases.  We  are 
often  surprised  to  find  a  phlebitis  develop  in  a  patient  who  has 


THE   COMPLICATIONS   AND   SEQUELS  lOI 

otherwise  had  an  ideal  convalescence.     In  only  one  of  the  present 
series  was  there  an  infected  wound. 

Appendicectomy i  left  i  right 

Appendicectomy,  curettage  and  perineorrhaphy .  .  i  left 
Cholecystostomy,  internal  Alexander;  curettage.  .  i  left  .  . 

Drainage  of  pelvic  abscess  . i  left  .  . 

Total  abdominal  hj^sterectomy i  left  i  right 

Gastrectomy i  left 

Cholecystostomy  and  appendicectomy i  left 

Cholecystectomy i  left 

Kraske;  colostomy i  left 

Tube  and  ovary,  appendicectomy i  left 

Ovarian  cyst i  left 

Mayo's  operation  for  prolapse i  left 

Ventral  hernia i  right 

Cholecystostomy i  right 

12  4" 

L.  B.  Wilson  ("Annals  of  Surgery,"  Dec,  19 12)  gives  a  statis- 
tical record  of  all  the  cases  of  fatal  post-operative  embolism 
occurring  in  the  Mayo  Clinic  during  the  years  1 899-1 91 1  inclusive. 

During  these  twelve  years  63,573  major  operations  were  per- 
formed, with  47  cases  of  fatal  post-operative  embolism.  Au- 
topsies were  made  in  41  of  the  fatal  cases. 

The  total  number  of  deaths  from  all  causes  was  864,  of  which 
the  fatalities  from  embolism  represent  5  per  cent. 

The  total  mortality  from  embolism  was  therefore  0.07  per 
cent. 

After  1372  operations  on  blood-vessels 2  deaths,  or  0.14  per  cent. 

After  3266  operations  on  the  thyroid 2  deaths,  or  0.06  per  cent. 

After  2281  operations  on  the  mouth i  death,    or  0.05  per  cent. 

After  2391  operations  on  the  stomach  and  duo-   ' 

denum 3  deaths,  or  0.12  per  cent. 

After  4597  operations  on  the  gall-bladder 9  deaths,  or  0.19  per  cent. 

After     389  operations  on  the  small  intestine i  death,    or  0.26  per  cent. 

After  9908  operations  on  the  appendix 4  deaths,  or  0.04  per  cent. 

After  2530  operations  on  the  colon  and  rectum 5  deaths,  or  0.02  per  cent. 

After  4501  operations  for  hernia 5   deaths,  or  o.ii  per  cent. 

After    900  operations  on  the  kidney i  death,    or  o.ii  per  cent. 

After     601  operations  on  the  prostate 4  deaths,  or  0.66  per  cent. 

After  7993  operations  on  the  uterus,  tubes,  and  ovaries  10  deaths,  or  0.13  per  cent. 

Of  the  47  cases,  25  were  males  and  21  females;  the  youngest 
was  twenty-five  and  the  oldest  seventy-two. 


102  ABDOMINAL   OPER.\TIONS. 

19  of  the  fatalities  occurred  within  the  first  week. 
21  of  the  fataUties  occurred  within  the  second  week. 
4  of  the  fataHties  occurred  in  the  third  and  one  each   on  the  twenty- 
sixth,  thirtieth,  and  sixty-fourth  days. 

In  36  cases  the  embolism  was  pulmonary,  in  10  cerebral,  and 
in  I  coronary. 

In  28  of  the  41  cases  examined  post-mortem  the  location  of 
the  primary  thrombus  was  in  the  field  of  operation  or  in  the  fem- 
oral veins;  in  4  cases  the  emboli  were  probably  cardiac;  in  9 
cases  the  seat  of  origin  was  not  determined. 

Summing  up,  Wilson  writes: 

"The  most  important  factors  concerned  in  extensive  post- 
operative thrombosis  are  as  follows: 

"  (a)  Injury  to  the  vascular  walls.  Rupture  of  the  intima  by 
cutting,  ligaturing,  or  clamping  causes  a  rapid  deposit  of  a 
fibrinous  thrombus,  which,  however,  is  normally  confined  to  an 
area  close  to  the  injury.  Over  this  the  endothelium  quickh' 
extends,  covering  the  thrombus  within  a  few  days.  It  is  probable 
that  such  small  terminal  thrombi,  when  covered  b}^  endothelium, 
rarely,  if  ever,  become  detached  and  form  emboli.  There  can 
be  no  question,  however,  but  that  the  constantly  present  small 
thrombi  in  injured  vessels  form  a  nucleus  for  the  subsequent  de- 
velopment of  large,  loose  thrombi  through  the  activity  of  other 
factors. 

"  (b)  Slowing  and  stagnation  of  the  blood  stream.  After 
operations  the  rapidity  and  volume  of  the  current  in  the  veins 
are  materially  lessened  for  a  considerable  distance  proximal  to 
the  first  incoming  venous  radicles.  Furthermore,  the  patients 
are  usually  kept  quiet  in  a  recumbent  posture,  thus  reducing  the 
force  and  rapidity  of  the  heart's  action  and  causing  a  general 
slowing  of  the  blood  current  throughout  the  entire  vascular  sys- 
tem, including  the  heart.  When  the  blood  stream  is  slower  or 
when  a  part  of  the  vascular  system  is  incompletely  filled,  a  dis- 
arrangement of  the  blood-cells  occurs,  the  white  cells  and  plate- 
lets reaching  the  periphery  of  the  stream  and  tending  to  attach 
themselves  to  the  vascular  walls. 

"(c)  Disintegration  of  the  corpuscles  of  the  blood  from  toxic 
substances. 

"While  such  toxic  substances  are  not  definitelv  known,  their 


THE   COMPLICATIONS   AND    SEQUELS.  IO3 

presence  is  assumed  from  their  apparent  action  in  the  severe 
secondary  anasmias  and  hepatic  diseases.  It  has  been  suggested 
that  this  factor  may  account  for  the  high  percentage  of  post- 
operative emboH  following  operations  on  the  gall-bladder.  It 
has  also  been  suggested  that  toxic  substances  reaching  the  cir- 
culation from  extensive  carcinomata  may  in  this  manner  cause 
marked  post-operative  thrombosis.  In  this  connection,  however, 
we  must  not  forget  the  rarity  of  post-operative  emboli  follow- 
ing extensive  operations  for  mammary  carcinomata. 

"(d)  Bacteraemia.  That  bacteria  and  their  toxins  are  the 
chief  causes  of  extensive  post-operative  thrombosis  as  well  as 
thrombosis  occurring  in  the  course  of  infectious  diseases  is  now 
fairly  well  established.  By  no  means  all  post-operative  thrombi 
occur  in  the  field  of  operation.  Phlebitis  and  a  resulting  throm- 
bus are  all  too  frequent.  The  last  decade  has  seen  a  very  marked 
extension  of  our  knowledge  of  the  frequent  infection  of  the  blood 
stream  by  bacteria.  This  is  particularly  so  in  chronic  diseases 
with  local  infection.  It  is  readily  conceivable  that  bacteria 
within  the  blood  stream  may  have  their  virulence  sufficiently 
reduced  to  prevent  their  setting  up  a  local  phlebitis  until  aided 
by  operative  traumatism  of  the  intima,  post-operative  slowing 
of  the  blood  current,  or  perhaps  even  the  effect  of  a  prolonged 
general  anaesthetic  on  the  leukocytes." 

As  soon  as  the  condition  is  discovered  it  must  be  treated 
very  seriously,  and  the  patient  warned  of  the  risks  of  disturbance 
of  the  limb. 

The  affected  limb  should  be  elevated  on  a  couple  of  pillows , 
and  some  warm  and  comforting  dressing  applied.  Lead  and 
opium  lotion,  or  warm  boracic  fomentations,  are  soothing  and 
grateful  to  the  patient,  but  they  must  be  applied  without  disturb- 
ing the  limb.  If  a  long  many -tailed  bandage  is  placed  from  the 
buttock  to  the  heel,  the  front  and  sides  of  the  limb  can  be  ex- 
posed, and  the  fomentations  applied  to  them  without  moving  the 
leg.  Flannel  bags  loosely  filled  with  bran,  and  made  hot  in  the 
oven,  keep  warm  for  a  couple  of  hours;  they  may  be  laid  over  a 
thin  wrap  of  gamgee  tissue  and  changed  as  often  as  necessary, 
without  anv  disturbance. 


104  ABDOMINAL   OPERATIONS. 

Local  treatment  must  be  continued  so  long  as  there  is  tender- 
ness in  the  course  of  the  vein,  and  the  first  movements  must  be 
made  with  great  gentleness  and  caution.  It  is  not  possible  to 
fix  arbitraril}^  any  time  for  the  commencement  of  movements, 
but  in  most  cases  four  or  six  weeks  must  be  allowed  to  elapse 
from  the  time  w^hen  the  last  extension  of  inflammation  oc- 
curred, before  movement  is  permitted. 

Lennander  suggested  some  years  ago  that,  in  cases  where 
thrombosis  of  the  veins  was  feared,  the  patient  should  be  kept 
in  the  Trendelenburg  position  for  a  few  days.  It  is  certainly 
an  advantage  in  some  cases  slightly  to  elevate  the  foot  of  the 
bed,  and  to  instruct  the  nurse  to  gently  rub  the  patient's  legs 
from  the  heel  upwards  for  a  few  minutes  two  or  three  times  daily. 

Stasis  and  sepsis,  probably  the  twin  causes  of  phlebitis,  are 
both  preventable.  The  latter  is  perhaps  not  under  our  control 
so  completely  as  we  think,  but  the  former  can  always  be  counter- 
acted. In  some  six  or  seven  cases  of  phlebitis  following  suppura- 
tive appendicitis  I  have  used  the  intravenous  injections  of  collar- 
gol  with  a  degree  of  success  which  will  urge  me  to  use  it  in 
like  cases  in  the  future. 

The  possibility  of  detachment  of  a  part  or  the  whole  of  the 
thrombus  must  never  be  forgotten  or  minimised.  Sudden  death 
has  occurred  upon  the  patient  first  attempting  to  stand,  or  to 
move  in  his  chair,  as  a  result  of  pulmonary  embolism. 

The  question  of  the  association  of  thrombosis  with  post- 
operative pneumonia  and  pleurisy  is  discussed  elsewhere. 


CHAPTER  IV. 

ABDOMINAL  INCISIONS. 

I  DO  not  think  that,  though  much  thereon  has  been 
written,  it  is  yet  adequately  recognised  that  the  steps 
in  the  making  and  in  the  repair  of  an  abdominal  wound 
are  of  the  very  greatest  importance.  I  doubt  whether  it 
is  any  exaggeration  to  say  that  the  circumstances  con- 
nected with  the  incision  are  among  the  most  important 
in  the  whole  range  of  abdominal  surgery.  For,  if  the 
incision  be  improperly  made,  by  the  free  division  of  mus- 
cular fibres  or  the  wilful  and  unnecessary  severing  of  nerve- 
trunks,  a  weakened  area  is  left  in  the  belly-wall  the  results 
of  which  may  be  of  even  greater  severity  than  those  con- 
ditions which  first  made  the  operation  advisable.  Too 
great  care  cannot  therefore  be  exercised  in  the  proper 
choice  of  a  method  of  incision  and  of  the  means  of  its 
securest  closure.  It  is  a  cardinal  rule  that  there  shall 
be  no  division  of  muscular  fibres  unless  it  is  absolutely 
necessary  for  a  sufficient  exposure  of  the  operation  field; 
muscular  fibres  are  always  to  be  separated,  never  to  be 
cut.  Nerves,  likewise,  are  things  to  be  treated  with  respect, 
and  in  many  cases  a  little  tact  in  the  arrangement  of 
a  wound  will  result  in  the  avoidance  of  any  injury  to 
them.  As  an  example  of  the  damage  that  may  result 
from  nerve  division,  I  may  quote  the  case  of  a  patient 
upon  whom  an  abdominal  nephrectomy  had  been  performed 
through  the  right  linea  semilunaris ;  several  nerves  had 
been  divided,  and,  as  an  inevitable  consequence,  the  rectus 
muscle  supplied  by  them  had  wasted  to  the  point  of  almost 
complete  disappearance.  An  enormous  hernia  had  developed, 
which   no   operation  could  possibly  cure.       In  some   instances 

105 


I06  ABDOMINAL  OPERATIONS. 

when  the  fibres  of  the  rectus  have  been  spht  in  the  per- 
formance of  cholecystotomy  or  gastro-enterostom}^  without 
reference  to  the  position  of  the  nerves,  that  part  of  the 
muscle  to  the  inner  side  of  the  incision  has  undergone 
atrophy,  and  a  hernia  has  consequently  developed.  At 
Czemy's  instance  Assmy  investigated  the  after-results  of 
cases  in  which  a  wide  vertical  splitting  of  the  rectus  fibres 
had  been  performed,  and  shewed  that  an  atrophy  of  that 
part  of  the  muscle  dissociated  from  its  nerve  supply  always 
followed.  In  cases  of  gastro -enterostomy,  therefore,  and  in 
the  operation  of  gastrostomy  as  performed  by  Hartmann 
and  Kocher,  the  rectus  muscle  is  not  split  at  all.  The 
anterior  sheath  is  divided,  the  whole  of  the  muscle  is  pulled 
to  the  outer  side,  and  an  incision  is  then  made  through 
the  posterior  sheath,  on  a  line  directly  behind  the  skin 
incision.  When  the  operation  is  completed,  the  muscle 
falls  back  into  its  normal  position. 

The  splitting  of  muscular  fibres  is  readily  and  safely 
accomplished  in  the  operation  of  gastrostomy,  as  was  first 
shewn  b}^  Howse ;  in  the  operation  of  removal  of  the  ap- 
pendix, as  was  shewn  by  McBumey;  in  the  operation  of 
removal  of  the  kidney,  as  was  shewn  by  Edwards,  and 
later  by  Abbe;  in  the  operation  of  left  inguinal  colotomy, 
and  so  forth.  If,  in  any  incision,  a  division  of  fibres  can 
be  effected  in  only  a  part  of  the  wound,  it  is  to  that 
extent  an  advantage  over  an  extended  division  of  the 
fibres. 

The  principles  which  guide  the  surgeon  in  the  making 
of  incisions  elsewhere  must  guide  him  here  also.  The 
cut  must  be  perfectly  clean;  the  edges  of  the  muscle  when 
separated  or  divided  must  be  sharply  defined;  there  must 
be  no  fraying  of  the  edges,  due  to  clums}^  or  untidy  work. 
Furthermore,  any  rough  handling  of  the  wound  during 
intra-abdominal  manipulations  must  be  expressly  avoided. 
If  a   difficult  manipulation  is   performed   through   an  opening 


ABDOMINAL   INCISIONS. 


107 


which  cramps  the  surgeon's  hands,  the  wound  edges  will 
be  bruised,  perhaps  soiled  with  escaping  fluids ;  indeed,  so 
great  damage  may  be  done  that  a  proper  healing  of  the 
wound  is  impossible.  All  incisions  must,  therefore,  be  of 
adequate,  though  never  of  undue,  length,  and  as  soon  as 
the  abdomen  is  opened  a  protection  to  the  lips  of  the 
incision  must  be  afforded  by  a  covering  of  flat  swabs, 
small  linen  squares,  or  other  soft  material  which  has  been 
thoroughly  sterilised 
and  wrung  out  of  hot 
sterile  salt  solution. 
Wounds  heal  more 
kindly  the  greater  the 
respect  with  which 
they  are  treated.  I 
feel  sure  that  some  of 
the  cases  in  which  a 
stitch  abscess  seems 
incapable  of  explana- 
tion may  be  ac- 
counted for  by  the 
fact  of  rough  hand- 
ling and  bruising  of 
the  cut  edges  of  the 
wound.  The  method 
of  incising  the  peri- 
toneum between  a 
clip  and  a  pair  of  forceps  is  shewn  in  flgure  19,  the  slitting 
up  of    the  peritoneum  on  the  forefinger  in  figure  20. 

The  special  incisions  used  in  each  region  will  be  dis- 
cussed in  detail  in  each  section. 

In  the  suture  of  incisions  great  care  is  also  necessary. 
When  muscular  fibres  have  been  separated  and  pulled  forci- 
bly apart,  the  moment  the  retractors  are  withdrawn  the  fibres 
come   together   and   close   the   temporary   gap.     How   strongly 


Fig.  19. — Incision  of  the  peritoneum.  The 
clip  is  held  by  the  assistant,  the  dissecting  for- 
ceps by  the  surgeon. 


io8 


ABDOMINAL  OPERATIONS. 


the  muscles  act  in  securing  the  closure  of  such  a  wound  can 
be  realised  if  the  finger  happens  to  be  therein  when  the  patient 
is  straining,  vomiting,  or  coughing.  The  finger  is  gripped 
in  a  sort  of  vice.  Nevertheless  I  usually  put  in  one  or  two 
sutures,  uniting  the  separated  edges,  to  ensure  perfect  accuracy 
of  apposition.      When   a   muscle    is    divided — say,    the    rectus 

— or  an  incision  is  made 
in  the  middle  line,  the 
wound  should  always  be 
stitched  up  in  layers.  I 
generally  use  three  lay- 
ers of  sutures  passed  in 
the  following  manner : 

A  Hagedorn  needle 
armed  with  a  long 
thread  of  No.  2  catgut 
is  used;  the  first  stitch 
is  taken  at  the  top  of 
the  wound,  and  picks 
up  the  peritoneum  and 
the  fascia  transversalis 
and  the  posterior  sheath 
of  the  rectus,  above  the 
umbilicus;  this  stitch  is 
continuous  and  extends 
from  the  top  to  the  bot- 
tom of  the  wound.  The 
needle  is  then  laid  aside, 
to  be  presently  resumed.  A  series  of  silkworm-gut  sutures  are 
now  passed  through  all  the  thickness  of  the  abdominal  wall 
which  is  not  embraced  by  this  first  catgut  suture;  that  is 
to  say,  that  the  skin  and  subcutaneous  tissues,  the  ante- 
rior sheath  of  the  rectus,  and  the  bulk  of  the  muscular  fibres 
of  the  rectus  are  all  included.  A  series  of  these  stitches  are 
passed,   at  intervals  of  about  three-fourths  of  an  inch,  along 


Fig.   20. — Division  of  the  peritoneum. 


ABDOMINAL    INCISIONS. 


109 


the  full  extent  of  the  wound,  using  the  transverse  scratches  marked 
on  the  skin  with  a  needle,  before  the  incision  was  made,  to  ensure 
accurate  apposition.  The  ends  are  left  loose  on  each  side,  and 
are  there  seized  by  a  clip.  These  interrupted  silkworm-gut 
sutures  being  introduced,  the  needle  armed  with  catgut  just  laid 
aside  is  taken  up  again.     The  same  suture,  without  knotting  or 


Fig.  21. — Suture  of  abdom- 
inal wall,  shewing  the  continuous 
suture  of  catgut. 


Fig.   22. — The  interrupted  sutures  of  silk- 
worm-o'ut. 


interruption,  then  returns  from  the  lower  end  to  the  upper,  pick- 
ing up  the  anterior  sheath  of  the  rectus  and  a  few  of  its  muscular 
fibres.  This  stitch  is  pulled  with  sufficient  tightness  to  get  a 
good  apposition  of  the  anterior  sheath  of  the  rectus.  When  the 
upper  end  of  the  wound  is  reached,  the  end  of  the  stitch  is  tied 
with  the  original  end  which  had  been  left  long,  and  the  ends  are 
cut  short.     The  condition  on  section  is  shewn  in  figure  24. 


no 


ABDOMINAL   OPERATIONS. 


The  interrupted  silkworm-gut  sutures  are  now  threaded 
through  pieces  of  fine  rubber  tubing  cut  to  the  correct  length,  tied, 
and  cut  short.     The  rubber  "bridges"  prevent  the  deep  tension 


Fig.   23. — Suture  of  abdominal  wall,  the  continuous  suture  returning  and  pick- 
ing up  the  anterior  sheath  of  the  rectus. 


Fig.  24. — Suture  of  the  abdominal  wall.  Section  shewing  the  position  of 
the  stitches:  a  and  a  are  the  different  parts  of  the  same  continuous  suture; 
b,  b,  interrupted  sutures. 

sutures  from  cutting  into  the  skin  and  marking  it.     For  the  exact 
apposition  of  the  skin  edges  I  have  frequently  used  Michel's  clips. 


ABDOMINAL    INCISIONS. 


Ill 


In  some  cases  where  the  abdomen  is  very  lax  there  may 
be  need  of  a  sHght  overlapping  of  the  cut  edges  of  the  ante- 
rior sheath  of  the  rectus.  It  has  been  shewn  that  the  greater 
part  of  the  strength  of  the  scar  lies  in  the  anterior  sheath  of 
the  rectus;  if  good  healing  is  obtained  in  that,  the  cicatrix 
is  not  likely  to  yield.  The  overlapping  adds  greater  strength, 
therefore,  to  the  scar.  The  methods  of  securing  this  overlap- 
ping are  shewn  in  the  figures. 

With  regard  to  the  material  which  is  used  for  the  buried 
suture,  nothing  can  be  better  than  medium  catgut  adequately 
sterilised.  The  use  of  silk  for 
buried  stitches,  though  advocated  by 
Kocher,  possesses  no  single  advan- 
tage over  catgut,  and  it,  question- 
less, possesses  more  than  one  dis- 
advantage. The  fallacy  which  sup- 
poses that  a  non-absorbable  suture 
continues  its  functions  perpetually 
has  been  exposed  times  without 
number.  The  wandering  of  such 
sutures  away  from  the  place  of 
their  introduction  is  a  matter  of 
common  observation.  If,  therefore, 
they  cease  after  a  time  to  perform 
their  necessary  functions,  they  are, 
for  their  purpose,   less    to    be    com-  ^.  ^,  ,       . 

^       ^  Fig.  25. — Ine  overlapping 

mended  than  sutures  which,  having     of  the  aponeurosis  of  the  rec- 

achieved     their     purpose,     disappear.       tus  in  the  suture  of  an  abdom- 

■^  mal  wound  (Noble  s  method). 

The   weight,  both  of   argument   and 

"experience,  is,  so  far  as  I  can  ascertain,  entirely  on  the  side 
of  those  who  use  catgut  rather  than  a  non-absorbable  material 
for  their  buried  sutures. 

The  method  of  suture  of  the  wound  just  described  has  been 
found  to  give  perfectly  satisfactory  results.  It  possesses  the 
advantage   of  giving  easy  and  accurate   apposition  to  all   the 


112 


ABDOMINAL   OPER-\TIOXS 


bo 


ABDOMINAL    INCISIONS. 


113 


layers  of  the  abdomen,  and  it  especially  supports  the  aponeu- 
rosis of  the  rectus,  in  that  through  this  structure  there  are 
sutures  of  apposition  and  of  wider  support. 

To    obtain    clean     and     perfect     healing     and     permanent 
strength  in  the  wound,  it  is  necessary,  therefore,  to  have 

(a)  clean-cut,  neat  incisions, 

(b)  an  absence  of  teasing  or  fraying  of  the  muscle  edges, 


Fig,  27. — Method  of  holding  a  curved  needle. 

(c)  protection  to  the  lips  of  the  wound  from  damage  by  in- 

struments, hands,  or  discharges, 

(d)  perfect  asepsis  throughout, 

(e)  accurate  suturing  in  layers,  sutures  of   apposition  and  su- 

tures of  support  both  being  used, 
(/)  an  absence  of  tension  in  the  wound. 


VOL.  I — s 


CHAPTER  V. 
PENETRATING  WOUNDS  OF  THE  ABDOMEN. 

A  DISTINCTION  has  been  drawn  between  penetrating  and 
perforating  w^ounds  of  the  abdomen,  but  the  distinction  is, 
for  cHnical  purposes,  neghgible,  for,  in  the  great  majority  of 
instances,  complete  penetration  of  the  abdominal  wall  im- 
plies also  a  perforation  of  some  viscus.  The  wounds  in  which 
the  greatest  damage  to  viscera  is  inflicted  are  generalh^  below 
the  umbilicus. 

The  viscera  are  injured  in  the  following  order  of  fre- 
quency: the  small  intestine,  the  liver,  the  stomach,  the  large 
intestine,  the  other  solid  viscera.  As  soon  as  the  intestine 
is  wounded,  if  the  wound  is  small,  there  is  a  prolapse  of  the 
mucous  membrane,  which  temporarily  blocks  the  opening 
and  prevents  a  discharge  of  the  intestinal  contents.  It  is  gen- 
erally supposed  that  the  leakage  of  the  contents  occurs  in- 
stantly upon  the  solution  of  continuity  in  the  bowel,  but  this 
is  not  the  case.  A  temporary  sealing  is  the  rule.  The  two 
conditions  which  aid  in  extravasation  are  intestinal  disten- 
sion and  the  manipulations  of  the  surgeon.  When  the  injury 
is  inflicted  upon  the  intestine,  the  damage  is  of  such  a 
character  as  to  cause  a  local  stunning  or  paratysis  of  the  bowel ; 
movement  is,  therefore,  arrested,  and  the  pouting  of  the 
mucosa  temporarily  blocks  the  opening.  When  distension 
occurs,  and  when  the  power  of  movement  returns,  then  leak- 
age may  occur.  ^^lurph}^  has  pointed  out  forcibty  that  ex- 
travasation occurs  chiefly  on  manipulation.  AVhen  the  solid 
viscera  or  the  mesentery  are  wounded,  haemorrhage  occurs, 
often   in   profuse   quantity. 

114 


PENETRATING   WOUNDS   OF    THE   ABDOMEN.  II5 

Douglas  writes: 

"The  effects  of  any  given  penetrating  wound  of  the 
abdomen  are  problematicaL  Their  nature  is  uncertain;  the 
tract  is  always  septic;  the  number  of  perforations,  unknown; 
compHcations  cannot  be  foretold.  If  a  ball  of  average  ve- 
locity enters  the  abdominal  cavity,  perforation  is  to  be 
expected.  That  it  may  find  its  way  between  the  interstices  of 
the  intestines  we  have  previously  admitted  as  a  possibility; 
but  that  it  may  produce  perforations  of  the  intestines  from 
one  to  twenty-eight  in  number  is  a  recorded  fact;  that,  if 
solid  viscera  lie  in  its  course,  it  will  traverse  these  and,  in  all 
probability,  will  wound  other  viscera.  Multiple  perforations  occur 
most  frequently  in  the  ileum,  and  are  oftenest  made  by  bullets 
that  pass  through  the  abdomen  obliquely  from  side  to  side." 

The  following  is  the  method  of  operating:  The  abdomen 
is  opened  through  a  median  incision  under  all  circumstances 
— lateral  incisions  must  not  be  used,  for  some  part  of  the  neces- 
sary investigation  cannot  be  conducted  through  them. 

The  escaping  blood-stained  discharge  is  cleared  away  as 
speedily  and  completely  as  possible,  and  if  there  is  evidence 
of  haemorrhage  occurring  at  the  moment,  the  solid  viscera, 
liver,  spleen,  kidneys,  and  the  mesentery,  must  be  first  exam- 
ined. If  injuries  thereof  be  found,  they  must  be  dealt  with 
forthwith,  for  injuries  of  the  hollow  viscera  are  far  less  urgent 
in  their  need  for  attention. 

Wounds  in  these  viscera  may  be  treated  by  suture,  by  cau- 
terisation, or  by  packing  with  gauze.  The  liver  and  the 
kidney  both  hold  sutures  well;  the  spleen  generally  tears  awav 
under  the  tension  of  a  stitch.  In  extensive  wounds  of  either 
spleen  or  kidney  the  organ  may  have  to  be  excised.  The 
sutures  used  for  the  control  of  the  haemorrhage  are  passed 
with  an  ordinary  large  intestinal  needle,  or,  in  the  case  of 
the  liver,  by  Kousnetzoff's  special  instrument.  If  the  kidney 
be  injured,  posterior  drainage  is  needed. 

The    solid    viscera    having    been    dealt   with,    the   intestine 


Il6  ABDOMINAL   OPERATIONS. 

must  be  methodically  examined.  Starting  from  a  fixed  point, 
— the  duodenojejunal  flexure  or  the  csecum, — the  whole  of  the 
small  intestine  is  rapidly  passed  through  the  fingers,  and,  as 
a  rent  is  exposed,  it  is  at  once  sutured.  Two  or  three  rents 
may  lie  close  together,  but  if  so,  it  is  better  to  suture  them 
than  to  excise  the  damaged  length  of  gut.  Resection  is  at 
times  necessary,  but  it  should  be  adopted  only  when  simple 
suture  is  impossible.  As  a  rule,  there  is  no  need  to  turn  the  in- 
testines out  of  the  abdomen,  but  this  may  be  done  if  necessar\\ 

As  the  bowel  is  examined,  the  mesenter}^  is  carefully 
searched  for  a  wound.  If  one  of  small  size  be  found,  it  may 
be  closed  with  a  single  suture.  If  there  be  a  large  one,  paral- 
lel to  the  bowel,  the  segment  of  gut  supplied  b}^  the  torn  ves- 
sels will  have  to  be  excised.  All  rents  in  the  intestine  are 
closed  by  a  double  layer  of  sutures  in  the  usual  way. 

Other  organs  are  now  examined— the  bladder,  large  in- 
testine, pancreas,  etc. — with  equal  care.  Though  a  detailed 
examination  of  all  parts  is  tedious  and  time-consuming,  it 
cannot  be  neglected  with  impunity.  Disaster  follows  per- 
functory  work. 

Lavage  and  drainage  are  adopted  in  the  manner  and  under 
the  circumstances  already  described.  It  is  safer  always  to 
drain. 

The  experience  of  surgeons  in  America  is  far  greater  in  this 
matter  than  that  of  any  European  surgeon.  I  cannot,  there- 
fore, do  better  than  quote  from  Dr.  Douglas's  admirable  work 
on  "The  Surgical  Diseases  of  the  Abdomen"  the  following 
paragraph  on  the  general  surgical  indications  in  cases  of  gun- 
shot wound  of  the  abdomen: 

"The  indications  in  any  given  case  of  gunshot  wound  of 
the  abdomen  are  to  relieve  shock,  control  haemorrhage,  re- 
move infectious  matter,  re-establish  the  continuity  of  the  in- 
jured viscera,  and  provide  direct  or  indirect  drainage.  If 
the  patient  is  in  great  pain,  a  hypodermatic  injection  of  mor- 
phin  should  be  immediately  given,   and  he  should  be  moved 


PENETR-VTING   WOUNDS   OF   THE   ABDOMEN.  II7 

with  greatest  care  to  his  home,  or  preferably,  to  a  hospital. 
Preparations  should  be  in  progress  for  an  abdominal  section. 
Stimulants  may  now  be  indicated.  If  penetration  is  not 
obvious,  this  question  should  be  determined  by  enlarging  the 
wound  of  entrance  under  cocain  anaesthesia.  If  penetration 
is  found,  or  if,  from  the  location  of  the  wound,  course  of  the 
bullet,  and  the  symptoms,  it  seems  at  all  probable,  a  general 
anesthetic,  preferably  ether,  is  administered,  and  laparotomy 
at  once  undertaken.  The  abdomen  is  opened  through  the 
line  a  alba  preferably,  as  the  track  of  the  bullet  is  always  sep- 
tic. The  location  of  the  wound  and  known  course  of  the  bul- 
let may  justify  lateral  opening.  When  the  peritoneum  is 
opened,  if  there  has  been  much  haemorrhage,  its  free  escape 
intensifies  the  existing  shock.  To  overcome  this,  the  assist- 
ant, who  has  previously  exposed  a  vein  and  introduced  a 
cannula,  now  proceeds  with  the  intravenous  infusion  of  normal 
saline  solution,  the  surgeon  having  by  this  time  secured  the 
principal  bleeding  points,  which  is  the  first  indication  on  open- 
ing the  abdomen.  If,  while  searching  for  these,  he  meets  with 
intestinal  perforations,  they  should  be  surrounded  with  gauze 
to  mark  them  and  to  prevent  extravasation.  The  increased 
vascular  tension  due  to  the  saline  infusion  will  develop 
bleeding  points  Avhich  might  otherwise  escape  notice.  This 
known  action  of  the  saline  prohibits  its  use  until  the  abdomen 
is  opened  and  the  chief  bleeding  points  are  controlled.  Our 
methods  of  hasmostasis  are  ligature,  suture,  actual  cautery, 
and  gauze  packing.  The  next  step  is  to  repair  the  injured 
viscera  by  the  special  methods  which  will  be  emphasised 
under  their  several  headings.  Unless  there  has  been  wide- 
spread extravasation  of  visceral  contents,  the  peritoneal  cav- 
ity should  not  be  flushed,  but  all  material  removed  by  gen- 
tle sponging  with  gauze.  After  the  intestinal  perforations 
are  closed,  an  ounce  of  "saturated  solution  of  sulphate  of  mag- 
nesium should  be  introduced  through  a  cannulated  needle  into 
a  coil  of  the  intestine  remote  from  the  wound,  and  this  punc- 
ture closed  by  suture.  The  question  of  drainage  in  gunshot 
wounds  of  the  abdomen  is  sub  jiidice.  Tifl-'any,  Coley,  and, 
indeed,  the  majority  of  surgeons,  .advise  drainage  in  all  cases 
in  which  viscera  are  injured.  Fenner's  personal  experience 
in  6  cases  with  5  recoveries  and   i   death,   all  treated  without 


Il8  ABDOMINAL   OPERATIONS. 

drainage,  and  my  own  experience  in  8  cases  with  2  deaths, 
lead  me  to  the  conclusion  that  drainage  is  not  desirable  if 
there  is  little  or  no  extravasation  and  if  the  operation  has  been 
done  within  six  hours.  In  operations  after  that  time  and  in 
all  cases  where  the  general  cavity  has  been  irrigated  multiple 
gauze  drains  should  be  employed.  The  bullet  wound  in  the 
parietes,  either  of  exit  or  entrance,  should  be  excised  and 
closed  by  sutures  or  left  open  and  drained  with  a  strip  of 
gauze." 

Dr.  Fenner  ("Annals  of  Surgery,"  vol.  xxxv,  p.  15)  reports 
six  cases  of  penetrating  wounds  of  the  abdomen  treated  by 
operation,  and  gives  statistical  tables  of  152  cases  treated  at 
the  Charity  Hospital,  New  Orleans,  between  January,  1892, 
and  January,  1901.  There  were  96  cases  of  gunshot  wound 
of  the  abdomen  with  visceral  injury.  Of  these,  71  died — • 
a  mortality  equivalent  to  73.95  per  cent. 

This  subject  is  discussed  further  in  the  chapters  dealing 
with  the  injuries  of  the  several  viscera. 


CHAPTER  VI. 

THE  SURGICAL  TREATMENT  OF  ACUTE  PERITONITIS. 

Cases  of  acute  peritonitis  may  be  classified  into  three 
groups : 

1.  Those  in  which  the   inflammation  is   locaHsed,  and  an 

abscess,    definitely    and    sharply    separated    from    the 
rest  of  the  peritoneum,  is  present. 

2.  Those  in  which  the  peritonitis  is  spreading  away  from 

the   original   source   of  infection,    but  in   which   some 
part  of  the  peritoneum  is  demonstrably  healthy. 

3.  Those  in  which  the  affection  of  the  peritoneum  is  uni- 

versal. 

The  following  remarks  apply  to  the  last  group.  The  prin- 
ciples of  treatment  in  the  first  and  second  groups  are  dealt 
with  elsewhere. 

OPERATION  IN  ACUTE  PERITONITIS. 

In  cases  of  acute  general  peritonitis  operation  is  indicated, 
firstly,  for  the  purpose  of  giving  vent  to  the  products  of 
inflammation — pus,  sero-pus — and  the  escaped  contents  of 
wounded  viscera;  secondly,  for  the  purpose  of  removing,  or 
of  otherwise  dealing  with,  that  organ  or  viscus  from  which 
the  inflammation  originally  started;  thirdly,  for  the  purpose 
of  cleansing,  so  far  as  is  possible,  the  walls  and  recesses 
of  the  infected  cavity ;  fourthly,  for  the  purpose  of  emptying,  and 
if  need  be  draining,  the  intestine  whenever  it  is  paralysed  in  over- 
distension ;  and,  fifthly,  for  the  purpose  of  proA'iding  for  a  further 
discharge  by  free  drainage  (which  can  only  be  of  a  temporary 
character) ,  or  for  shutting  oft'  by  gauze  packing  the  most  infected 
part  of  the  cavity.  I  do  not  think  that  in  any  abdominal  opera- 
tions ever  undertaken  b}''  the  surgeon  the  need  for  speed,  com- 


I20  ABDOMINAL   OPERATIONS. 

bined  with  aptness,  can  be  greater  than  in  these.  Slow  opera- 
tions mean  death  from  shock;  imperfect  operations  mean  death 
from  a  continuance  of  the  acute  inflammation.  Perfunctory 
work  and  slow  work  are  both  out  of  place. 

It  must  be  the  surgeon's  duty,  therefore,  to  ensure  that 
every  precaution  is  taken  to  lessen  or  avoid  the  incidence  of 
shock,  and  to  see  that  absolutely  everything  needed  in  the 
operation  is  ready  before  the  ansesthetic  is  administered. 

As  a  rule,  an  enema  of  lo  or  12  ounces  of  warm  water 
with  an  ounce  of  brandy  and  a  hypodermic  injection  of  10 
minims  of  liquor  strychninae  will  be  given.  The  cleansing  of 
the  abdomen  can  generally  be  done  before  the  ether  is  given. 
The  abdomen  is  opened  by  a  free  incision  in  the  middle  line. 
As  soon  as  the  peritoneum  is  incised,  the  character  of  the  es- 
caping fluid  is  noticed.  The  fluid  in  the  case  of  perforated 
gastric  ulcer  is  generally  turbid,  abundant,  and  flakes  of  lymph 
or  of  food  are  floating  in  it.  When  the  duodenum  is  perfor- 
ated, the  fluid  may  be  bile-stained.  In  both,  the  gas,  which 
is  also  present  free  in  the  peritoneal  cavity,  is  odourless;  this 
is  a  point  of  considerable  diagnostic  importance,  for  if  the  gas 
be  of  strong  odour,  perforation  in  the  stomach  or  duodenum 
can  almost  certainly  be  excluded.  If  the  fluid  be  darkish 
brown  and  offensive,  a  low  perforation  of  the  intestine  will 
be  suspected.  In  cases  of  typhoid  fever  in  which  an  ulcer 
perforates  the  fluid  is  turbid,  contains  brownish  material  and 
particles  of  curdled  milk  or  other  food.  The  characters  of 
the  fluid  are  not  always  such  as  to  give  help  to  the  surgeon. 
Pus  may  result  from  a  variety  of  conditions,  and  its  abomi- 
nable offensi\'eness,  though  suggesting  a  perforation  of  the  ap- 
pendix more  decidedly  than  any  other  lesion,  is  not  pathog- 
nomonic. 

.The  hand  or  three  fingers  are  now  introduced  within  the 
abdomen  with  the  most  scrupulous  gentleness  and  care.  The 
damage  done  by  clumsiness  now  may  be  irreparable;  the 
rough  and  forcible  pushing  of  the  hand  indiscriminately  within 


SURGICAL   TREATMENT   OF   ACUTE    PERITONITIS.  121 

the  abdomen  may  rupture  the  thin  and  tender  peritoneum 
tightly  stretched  over  an  inflamed  intestine,  and  leakage  of 
highly  infective  organisms  through  these  rents  may  produce 
a   fatal   inflammation. 

The  search  within  the  abdomen  is  purposeful.  The 
caecum  is  first  sought,  in  order  to  ascertain  the  condition  of 
the  appendix,  and  in  order  to  discover  the  condition,  as  to  dis- 
tension, of  the  c^cum  itself.  If  the  appendix  be  discovered 
to  be  gangrenous,  it  is  dealt  with  at  once  in  the  usual  manner. 
If  the  caecum  is  found  distended,  it  is  clear  that  the  lesion, 
if  of  an  obstructive  character,  is  in  the  large  intestine.  The 
sigmoid  is  then  sought;  if  that  too  is  distended,  the  condition 
(if  the  rectum  be  unobstructed,  which,  presumably,  it  is 
known  by  previous  experience  to  be)  is  one  of  general  par- 
alytic distension  of  the  intestine  due  to  a  universal  inflam- 
mation. If  a  search  has  so  far  proved  ineffective  and  the  con- 
dition of  the  patient  permits  a  further  investigation,  a  close 
scrutiny  should  be  made  in  order  to  discover  any  thick  local- 
ised deposit  of  lymph.  This,  in  the  majority  of  instances, 
will  lead  to  the  discovery  of  the  source  of  ofl:ence,  for  the  first 
and  instant  response  of  the  peritoneum  to  injury  is  the  abun- 
dant outpouring  of  lymph  and  fluid.  If  it  be  noticed  that 
though  fluid  is  everywhere  present  a  thick,  "wash-leathery" 
deposit  of  lymph  is  conflned  to  one  area  alone,  in  that  area 
the  perforation  or  other  source  of  irritation  may  confldently 
be   sought. 

The  primary  disease  having  been  discovered  and  having 
been  dealt  with  as  seems  best,  the  question  next  arises  as  to 
the  surest  means  of  cleansing  the  peritoneal  cavity.  With 
regard  to  this  matter  there  are  still  widely  divergent  opinions 
among  surgeons  of  great  experience.  Some  advocate  the 
free  universal  flushing  of  the  peritoneum;  others  are  convinced 
that  this  is  largely  a  measure  of  harm,  and  are  content  w4th 
gentle  sponging,  while  still  others  rely  solely  upon  the  inser- 
tion of  drains  of  rubber  tubing. 


122  ABDOMINAL   OPEIL\TIONS. 

M3'  own  practice  in  cases  where  there  are  particles  of  food, 
lymph,  or  a  very  turbid  exudate  is  at  once  to  make  a  second  in- 
cision in  what  seems  the  most  appropriate  place  for  affording  free 
drainage — in  the  case  of  the  appendix,  the  incision  is  made 
over  the  iliac  fossa.  Through  this  incision  a  piece  of  large 
rubber  tubing  attached  to  a  funnel  is  introduced,  and  a  free 
irrigation  of  hot  sterile  salt  solution  is  begun.  If  both  renal 
pouches  are  affected  and  a  copious  deposit  of  pus  is  found  in 
them,  incisions  are  made  into  them  from  above  the  iliac  crest. 
Incision  and  drainage  in  these  places  may  serve  to  prevent 
a  subphrenic  abscess.  I  frequently  make  three,  and  occasion- 
ally even  five,  incisions  into  the  abdomen,  each  large  enough 
to  take  a  split  rubber  tube.  It  is  impossible  to  drain  the  whole 
peritoneal  cavity  through  a  simple  opening — the  difficulty,  in- 
deed, is  to  drain  it  adequately  through  many  openings.  Such 
drainage  is  only  temporar}^  owing  to  the  rapid  encapsulation  of 
the  tube.  None  the  less  it  is  of  supreme  advantage  and  im- 
portance. 

It  is  constantty  said  that  the  lavage  of  the  peritoneal 
cavity  is  largely  futile  because  the  recesses  and  complexities 
of  the  peritoneum  are  such  that  no  flushing,  however  care- 
fully executed,  can  possibly  clean  out  all  the  collections.  I 
am  disposed  to  doubt  the  accuracy  of  these  observations. 
With  a  supple  rubber  tube  of  good  diameter,  a  free  flow"  of 
saline  solution,  and  easy  means  of  escape  b}^  tubes  introduced 
into  other  incisions,  a  reasonably  complete  cleansing  is  cer- 
tainly possible. 

It  is  the  practice  of  man}^  surgeons  to  leave  as  much  fluid 
as  possible  in  the  peritoneal  cavity.  Whether  much  or  little 
is  left  seems  a  matter  of  indift'erence,  for  if  much  be  left,  there 
is  probably  an  easy  escape  for  it  within  a  very  short 
time  through  the  various  incisions,  each  holding  its  own  drain- 
age-tube. As  a  rule,  I  mop  gently  any  specially  infected  part 
of  the  abdomen  and  empty  away  all  excess  of  fluid.  A  rub- 
bing of  the  peritoneum,  when  gauze  swabs  are  introduced  for 


SURGICAL   TREATMENT    OF   ACUTE    PERITONITIS.  I23 

mopping  purposes,  is  to  be  expressly  avoided,  for  this  rough 
friction  probably  does  more  hurt  to  the  peritoneum  than  any- 
thing else. 

As  a  rule,  only  the  original  incision  needs  to  be  sutured; 
the  other  openings  are  purposely  made  of  a  size  no  larger  than 
is   necessary   for   the   easy   introduction   of   the   drainage-tube. 

The  making  of  the  multiple  incisions  in  this  manner  does 
not  in  the  least  weaken  the  abdominal  wall,  for  the  surgeon 
is  careful  to  split  through  the  muscles  everywhere,  and  not 
to  cut  them  rashly;  and  is  careful,  also,  to  avoid  the  section 
of  nerves. 

There  are  many  surgeons  of  ripe  experience  who  advise 
that  in  order  to  secure  more  complete  cleansing  of  the  perito- 
neum the  whole  intestine  should  be  brought  outside  the  inci- 
sion, or  at  least  well  into  the  w^ound,  loop  by  loop,  and 
thoroughly  cleansed  by  washing  or  wiping  "with  consider- 
able force"  the  entire  surface  of  bowel  and  mesentery.  I  have 
never  carried  out  this  advice,  and  I  cannot  think  that  it  is 
one  likely  to  advance  the  patient's  chances  of  survival.  It 
is  a  little  too  heroic. 

J.  A.  Blake  ("  Amer.  Jour.  Med.  Sci., "  1907,  vol.  i),  in  a  paper 
on  the  treatment  of  diffuse  suppurative  peritonitis,  has  advo- 
cated a  less  universal  adoption  of  peritoneal  drainage  in  these 
cases.     He  lays  down  the  following  operative  rules : 

1.  Remove  as  rapidly  as  possible  through  a  small  incision 
the  origin  of  the  inflammation. 

2.  Wash  or  irrigate  the  peritoneal  cavity  with  a  double  irri- 
gator. 

3.  Drain  as  little  as  possible,  and  do  not  attempt  to  drain 
the  general  peritoneal  cavity. 

After  the  lavage  has  been  completed  he  closes  the  incision, 
leaving  a  small  opening  for  wound  drainage.  The  drain  simply 
passes  through  the  wound,  and  just  enters  the  abdomen,  allow- 
ing the  excess  of  the  irrigating  fluid  to  escape  and  preventing 
wound  suppuration. 


124  ABDOMINAL   OPERATIONS. 

If  deep  drainage  is  necessary,  owing  to  imperfect  removal  of 
the  cause  of  the  peritonitis,  insecure  closure  of  a  perforation,  or 
necrotic  material,  a  suitable  drain  is  carried  down  to  the  site  in  a 
manner  similar  to  that  adopted  when  there  is  no  diffuse  peri- 
tonitis.    Blake  writes: 

"With  regard  to  drainage,  if  after  irrigating  one  can  feel  as- 
sured that  there  is  nothing  left  in  the  peritoneum  but  what  can 
be  absorbed,  there  is  no  need  of  drainage.  If  there  is  something 
left  which  probably  will  not  be  absorbed,  one  should  drain,  but 
should  only  drain  down  to  the  doubtful  substance." 

He  gives  the  following  statistics: 

Cases  of  Diffuse  Peritonitis  Due  to  Appendicitis 
Deaths 15 

Not  drained 7 

Drained 8 

7  to  stump  of  appendix,  i  to  pelvis 
Recoveries 63 

Not  drained 31 

Drain  to  stump  of  appendix 28 

Drain  to  pelvis 4 

Total 78 

Cases  Due  to  Gastric  or  Duodenal  Extravasation 
Deaths 4 

Not  drained 2 

Drain  to  suture 2 

Recoveries 9 

Not  drained 4 

Drain  to  suture 4 

Drain  to  pelvis i 

Total 13 

Typhoid  Perforations 
Deaths 4 

Drained 3 

Drain  of  pelvic  abscess i 

Recoveries 4 

Not  drained 2 

Drained 2 

Total 8 

A  further  point  to  be  considered  in  all  these  desperate 
cases,  when  distension,  even  to  paralysis  of  the  gut,  is  present, 


SURGICAL   TREATMENT   OF   ACUTE   PERITONITIS.  1 25 

lias  reference  to  the  need  for  evacuating  the  contents  of  the 
intestine  by  enterotomy  or  enterostomy.  Tliere  can  be  no 
question  that  in  many  cases  a  free  evacuation  of  the  stagnant 
gas  and  faecal  material  is  entirely  an  advantage.  The  intes- 
tines are  little  likely  to  regain  their  power  of  contraction  when 
distension  has  passed  beyond  a  certain  point,  and  when  this 
power  returns,  there  seems  to  be  a  return  also  of  the  rapidity 
of  absorption  of  the  intestinal  contents.  These  are  of  an  in- 
tensely toxic  character,  as  we  know  by  abundant  painful  ex- 
perience and  by  the  experiments  of  Kader.  The  emptying 
of  the  intestine  should,  therefore,  be  considered  an  almost 
routine  practice.  If  carried  out  in  the  manner  described  else- 
where, with  the  help  of  a  glass  tube  inserted  into  the  bowel, 
upon  which  the  gut  is  drawn,  the  emptying  of  the  intestines 
is  a  simple,  speedy,  and  satisfactory  matter.  The  opening, 
of  course,  is  made  as  low  down  in  the  intestine  as  possible.  Len- 
nander  makes  two  or  three  openings  in  the  intestines  at  various 
levels,  establishing  at  each  a  "Witzel  fistula."  The  lowest 
of  these  fistulas  leads  into  the  caecum,  and  is  used,  if  need 
be,  for  administering  liquid  food  by  the  colon. 

Dr.  Andrew  McCosh  has  suggested — and  I  have  frequently 
acted  upon  this  important  suggestion — that  a  large  dose  of 
sulphate  of  magnesia  should  be  introduced  into  the  intestine, 
high  up,  for  the  purpose  of  ensuring  a  return  of  peristalsis. 
Dr.  McCosh  (Intern.  Soc.  of  Surgery,  Sept.,  1905)  wrote:  "  Though 
I  still  employ  this  method  I  am  less  enthusiastic  as  to  its  value. 
Some  surgeons,  however,  regard  it  with  favour  and  I  am  still 
inclined  to  believe  that  it  is  often  beneficial.  If  the  source  of 
the  peritonitis  has  not  been  removed  it  of  course  should  never 
be  employed. " 

As  soon  as  the  patient  returns  to  bed,  he  is  propped 
up  almost  in  the  sitting  posture.  This  is  far  more  comfort- 
able for  him,  allows  drainage  down  towards  the  pelvis,  and 
aw;ay  from  the  diaphragm,  and  thereby  lessens  the  risks  of 
that  most  serious  complication,  subphrenic  abscess. 


126  ABDOMINAL   OPERATIONS. 

B.  H.  Buxton  ("Jour.  Med.  Research,"  Boston,  March,  1907) 
has  shown  that  bacteria,  when  injected  into  peritoneal  cavity, 
even  in  minute  doses,  reach  the  circulation  in  a  few  minutes  by 
way  of  the  lymphatics  of  the  diaphragm.  If  these  results  be 
applied  to  man,  then  the  Fowler  position  is  indicated  to  avoid  a 
rush  of  bacteria  toward  the  diaphragm  and  flushing  the  abdom- 
inal cavity  is  not  indicated. 

Of  late  years  irrigation  in  cases  of  acute  peritonitis  is  less  fre- 
quently adopted  than  formerly.  Surgeons  have  learnt  the  im- 
portance of  respecting  the  diaphragmatic  area,  the  risk  of  washing 
away  phagocytes  by  indiscriminate  irrigation. 

Warmth  should  be  freely  applied  to  the  patient;  rubber 
bottles  filled  with  hot  water  and  swathed  in  flannel  should 
be  placed  close  to  the  body  and  extremities.  Care  is,  of  course, 
taken  to  ensure  that  the  patient  is  not  burnt  by  these.  In 
many  cases,  especially  if  vomiting  has  been  a  troublesome 
and  persistent  symptom,  the  stomach  must  be  washed  out 
before  the  patient  leaves  the  operating-table,  and,  if  neces- 
sary, an  ounce  or  two  of  hot  water,  in  which  some  Rochelle 
salts  or  sulphate  of  magnesia  is  dissolved,  is  allowed  to  re- 
main in  the  stomach.  If  vomiting  persists  after  the  opera- 
tion, the  stomach  may  again  be  washed  out,  with  great  re- 
lief to  the  patient. 

If  collapse  occurs  or  deepens,  the  infusion  of  about  i^ 
to  2  pints  of  saline  solution  into  the  median  basilic  or  other 
accessible  vein  will  help  the  patient  to  rally.  This  may  be 
repeated  at  the  end  of  twelve  to  twenty-four  hours  if  necessary. 

I  have  used,  with  striking  success  in  many  cases,  the 
method,  introduced  by  Kocher,  of  continuous  subcutaneous 
infusion.  Two  needles  connected  by  india-rubber  tubes  and  a 
Y  tube,  with  a  funnel,  are  introduced  into  the  subcutaneous 
tissue,  one  into  each  thigh  or  one  into  each  axilla.  Normal 
saline  solution  is  poured  into  the  funnel  and  drains  slowly  into 
the  tissue.  About  one  pint  in  an  hour  is  the  best  quantity  to 
introduce.     Care  must  be  taken  to  keep  the  fluid  at  the  proper 


SURGICAL   TREATMENT   OF   ACUTE   PERITONITIS.  12/ 

temperature  (about  105°  F.  in  the  fininel).  To  the  first  pint 
of  the  saHne  solution  (0.9  per  cent.)  ma}^  be  added  2  to  8  per 
cent,  of  glucose  and  ^  to  2  per  cent,  pure  alcohol;  subsequently, 
saline  solution  only  is  given.  For  many  cases  continuous  rectal 
injection  acts  equally  well,  and  it  is  easier  to  keep  at  the  proper 
temperature. 

The  bowels  should  be  encouraged  to  act  as  soon  as  pos- 
sible by  the  administration  of  turpentine  enemata  or  by  the 
injection  of  glycerine. 

Hypodermic  injections  of  str}^chnine,  say  5  minims  every 
four  hours,  can  often  be  given  with  advantage. 

It  is  worthy  of  note  that  the  method  above  described  does 
not  meet  with  universal  sanction.  There  are  surgeons  who 
do  not  use  the  method  of  flushing  the  peritoneal  cavity,  be- 
ing content  with  incision  and  drainage;  and  there  are  others 
who  follow  Dr.  Joseph  Blake,  of  New  York,  in  his  practice 
of  free  irrigation  of  the  peritoneum  without  drainage. 

Dr.  Blake  writes :  "I  was  formerly  a  warm  advocate  ol 
abundant  drainage;  later  I  became  convinced  of  the  uttei 
impossibility  of  draining  every  part  of  the  peritoneal  cavit>', 
for  it  was  evident  that  the  drains  were  soon  isolated  by  ad- 
hesions, so  I  next  confined  myself  to  the  drainage  of  the  field 
of  operation,  and  then,  perceiving  that  the  other  similarly 
affected  regions  of  the  peritoneum  took  care  of  themselves, 
I  omitted  drainage  almost  entirely  and  only  employed  it  when 
the  presence  of  necrotic  tissues  or  haemorrhage  demanded  it." 

My  own  practice  in  these  cases  is  to  ensure,  as  far  as  pos- 
sible, cleansing  by  free  lavage,  free  drainage,  and,  if  need  be, 
emptying  of  the  intestine  by  enterotomy  or  enterostomy. 


CHAPTER  VII. 
TUBERCULOUS  PERITONITIS. 

Three  forms  of  tuberculous  peritonitis  are  recognised: 

1.  The  ascitic  or  miliary  form. 

2.  The  fibrous  form. 

3.  The  suppurative  (ulcerative)  form. 

It  is  of  the  first  importance  from  the  surgical  point  of  view 
to  bear  constantly  in  mind  the  fact  that  the  various  forms  of 
tuberculous  peritonitis  are  secondary,  and  not  primary,  diseases. 
The  invasion  of  the  peritoneum  occurs  from  some  organ  within 
the  abdomen  which  itself  has  been  attacked  by  a  tuberculous 
process.  Just  as  acute  septic  peritonitis  is  due  to  the  spread  of 
infection  from  some  organ  which  has  been  first  attacked  (the 
appendix,  for  example),  so  in  tuberculous  peritonitis  the  peri- 
toneal invasion  starts  out  from  some  organ  which  has  been 
primarily  affected  by  the  disease.  The  importance  of  this 
knowledge  of  the  secondary  character  of  the  tuberculous 
process  in  the  peritoneum,  so  far  as  concerns  treatment,  cannot 
well  be  exaggerated. 

I.  In  the  ascitic  form  the  peritoneal  cavity  is  filled  with  a 
clear  serous  efl:usion.  The  peritoneum,  both  parietal  and  vis- 
ceral, is  covered  with  small  nodules,  which  are  placed  as  close 
together  as  is  possible.  Wherever  one  looks  or  feels  it  is  the 
same, — the  peritoneum  is  thickly  studded  with  fine  rough  gran- 
ules. A  piece  of  intestine,  allowed  to  escape  from  the  wound, 
shews  a  peritoneal  surface  that  has  lost  all  its  smoothness  and 
polish.  The  surface  is  rough,  congested,  red,  and  thickened. 
If  carelessly  handled,  it  is  apt  to  bleed,  or  some  of  the  outer  coat 
may  slither  away  beneath  the  finger.  The  fiuid  is  free  in  the 
peritoneum,  there  are  no  loculi,  and  there  are  no  adhesions, 
as  a  rule. 

12S 


TUBERCULOUS    PERITONITIS.  I29 

In  a  certain  number  of  cases  the  deposit  of  tubercles  may 
be  so  thick  that  a  definite,  palpable  tumor  may  be  formed. 
Thus  the  omentum  may  be  an  inch  or  even  more  in  thickness, 
and  it  may  be  shortened  and  puckered  upwards  to  the  greater 
curvature  of  the  stomach.  The  primary  source  of  infection,  a 
Fallopian  tube,  the  appendix,  an  ulcer  in  the  intestine,  or  a 
mesenteric  gland,  may  be  recognised  or  may  be  securely  walled 
off  in  a  mass  of  protective  adhesions. 

2.  The  fibrous  form  is  comparatively  rare.  It  is  due  to  a 
similar  deposit  of  tubercles  to  that  already  described,  but  there 
is  a  complete  absence  of  serous  effusion.  The  opposing  peri- 
toneal surfaces  have  everywhere  become  adherent,  until,  at  the 
last,  there  is  no  peritoneal  cavity  left.  However  extensively 
adhesions  are  separated,  adhesions  still  are  met  with.  It  is 
quite  exceptional  to  find  even  a  few  drops  of  serous  effusion. 

In  certain  rare  instances  a  combination  of  the  conditions 
described  above  may  be  found.  There  is  a  localised  cystic  swell- 
ing whose  walls  consist  solely  of  fibrous  tissue,  wdth  a  deposit  of 
tubercles  universally  distributed,  separating  the  fluid  from  the 
intestines  which  lie  immediately  outside.  The  peritoneal  cavity 
elsewhere  is  obliterated  by  adhesions,  and  tubercles  may  be  seen 
scattered  everywhere.  I  have  recently  operated  upon  such  a 
case, — a  cystic  tumour  without  pedicle  enucleated  from  a  bed 
formed  by  the  intestines,  which,  in  other  parts,  were  so  adherent 
that  separation  was  impossible.  Cystic  swellings  may  develop  in 
the  pelvis  of  women  and  form  tumors  resembling  ovarian  cysts. 
Their  walls  are  fibrous  and  thick,  and  into  their  cavity  the  patu- 
lous end  of  a  tuberculous  Fallopian  tube  will  be  found  to  open. 

3.  The  suppurative  form  is  found  in  those  cases  in  which  the 
tubercles,  deposited  in  the  peritoneum,  have  undergone  case- 
ation. As  the  result  of  a  mixed  infection,  suppuration  occurs. 
In  such  circumstances  it  is  constantly  found  that  the  pus  becomes 
localised.  A  general  distension  of  the  peritoneal  cavity  with  pus 
is  rare ;  the  rule  is  to  find  one  or  more  loculi  completely  separate 
one  from  another,  each  containing  fluid.     In  all,  the  fluid  may  be 

VOL  I Q 


130  ABDOMINAL   OPER.\TIONS. 

purulent,  or  pus  may  be  found  in  one,  and  clear  or  turbid  fluid 
in  another.  The  visceral  walls  bounding  an  abscess  cavity  are 
often  attenuated,  even  to  such  a  degree  that  the  gentlest  hand- 
ling may  result  in  rupture.  This  form  of  the  disease  is  more 
common  in  children. 

The  question  as  to  the  advisability  or  necessity  for  surgical 
treatment  has  excited  great  interest  and  frequent  discussion. 
The  opinion  of  surgeons  is  now  almost  unanimously  in  favour  of 
operation  in  the  ascitic  form  of  the  disease,  and  against  operation 
in  both  the  fibrous  and  the  ulcerous  forms.  In  the  ascitic  form 
the  results,  both  immediate  and  remote,  are  good;  the  immedi- 
ate results  are,  indeed,  very  often  surprising.  The  patient  al- 
most at  once  makes  haste  to  improve;  he  eats  better,  puts  on 
weight,  and  his  appearance  improves  almost  beyond  recognition. 
The  permanent  results  are,  perhaps,  not  quite  so  remarkable. 
After  a  period  of  the  brightest  health,  the  patient's  vitality  may 
flag ;  other  deposits  than  that  in  the  peritoneum  may  take  on  a 
great  activity,  and  patches  of  disease  in  the  lungs,  or  pleura,  or 
the  generative  organs,  may  grow  apace.  This  is  especially  the 
case  when  the  primary  source  of  the  disease  has  been  allowed 
to  remain.  If  the  abdomen  has  been  merely  opened,  emptied 
of  fluid,  and  closed,  the  primary  source  of  infection,  the  Fallo- 
pian tube  or  the  appendix,  may  continue  to  pour  out  its  supply 
of  active  bacilli  into  the  peritoneal  cavity  as  it  did  before.  The 
effusion  reappears,  and  a  second,  or  a  third,  or  a  fourth  operation 
may  be  necessary.  When,  however,  the  primary  disease  has 
been  removed,  the  results  are  very  much  more  satisfactory. 
"Recurrence,"  so  called,  of  tuberculous  peritonitis,  means  con- 
tinued infection. 

Before  reckoning  up  the  advantages  of  surgical  treatment 
in  this  disease  it  is  necessary  to  recall  the  fact  that  tuberculous 
disease  of  the  peritoneum  tends  not  rarely  to  spontaneous  re- 
cover^^  Patients  may  remain  ill  from  the  disease  for  months, 
but  under  careful  nursing,  with  generous  but  prudent  feeding 
and  a  plentiful  supply  of  fresh  air,  they  may  slowly  return  to 


TUBERCULOSIS    PERITONITIS.  I3I 

health.  Borchgrevink  comes  to  the  conclusion  that  approxi- 
mately one-third  of  all  cases  recover  spontaneously  or  under 
careful  medical  treatment.  This  estimate  is  probably  in  excess 
of  the  truth,  and  it  does  not  take  into  account  the  cases  in  which, 
after  months  or  even  years  of  apparent  relief,  the  tuberculous 
process  spreads  to  other  parts  and,  by  its  increase,  causes  death. 
The  results  of  surgical  treatment  haA'C  been  studied  by 
many  writers.  Rorsch,  writing  in  1895,  gave  the  result  of  his 
examination  into  the  histories  of  358  cases.  Thirty-two  pa- 
tients died  as  a  result  of  the  operation;  51  patients  died  within 
eighteen  months  as  a  result  of  a  recurrence  of  this  disease,  or  of 
an  extension  of  disease  in  areas  affected  before  the  operation 
was  undertaken.  The  remaining  275  cases  all  shewed  improve- 
ment ;  in  63  of  these,  over  two  years  had  elapsed  from  the  time 
of  the  operation,  and  all  these  patients  were  in  good  health 
and  free  from  obvious  disease. 

Wunderlich,  in  a  series  of  344  cases,  found  that  81  patients 
died  as  the  result  of  the  operation.  Of  the  remainder,  80 
patients  had  remained  well  for  over  three  years. 

Margaracci  reported  250  cases  of  laparotomy  in  Italy  with 
85  per  cent,  of  recoveries;  Adossides,  405  operations  with  75 
per  cent,  of  recoveries. 

These  lists  undoubtedly  include  cases  all  of  which  were  not 
suitable  for  operation.  If  those  patients  suffering  from  the  as- 
citic form  are  alone  treated  by  operation,  the  results  will  shew 
a  permanently  good  result  in  at  least  50  to  60  per  cent,  of  cases. 
In  Czerny's  clinic  40  to  50  per  cent,  of  cures  are  reported,  and 
in  recent  years  these  results  ha^-e  been  surpassed. 

Operations  performed  upon  patients  aff'ected  by  the  fibrous 
form  of  disease  are  rarely  productive  of  any  good  result,  and  some 
harm  may  undoubtedly  be  done  by  the  attempted  separation 
of  adherent  coils  of  bowel. 

In  such  cases,  the  intestine  may  be  wounded  when  the  ab- 
dominal incision  is  made,  for  there  may  be  a  firm  agglutination 
between  the  bowel  and  the  parietal  peritoneum. 


132  ABDOMINAL  OPERATIONS. 

In  a  few  instances  circumscribed  pseudocysts  may  form 
between  the  adherent  coils  of  intestine;  often  small,  they  may 
at  times  increase  in  size  rapidly  and  come  at  the  last  to  form 
cysts  having  a  capacity  of  several  pints.  Such  C3''sts  have  no 
walls  other  than  the  walls  of  the  bowel  around  them;  their 
remoA-al  is  then  impossible.  When  opened,  they  should  be  emp- 
tied, wiped  out  carefully,  and  not  drained.  As  Murphy  points 
out,  these  cyst-cavities  are  easily  infected,  and  once  infected 
the\^  continue  as  suppurating  sinuses  for  months. 

The  suppuratiA'e  form  of  the  disease  is  often  secondary  to  a 
suppurative  disease  in  the  Fallopian  tube  or  in  the  intestine. 
AYhen  treated  by  operation,  the  results  are  sometimes  disastrous, 
for  faecal  fistula  may  be  caused  by  the  gentlest  handling  of  the 
bowel,  or  the  gut,  already  w^eakened  by  disease,  ma}^  burst, 
either  at  once  or  in  a  few  days,  into  the  abscess  cavity  after  the 
pus  has  been  allowed  to  escape. 

There  are  cases,  however,  of  localised  suppuration  which  are 
rightly  treated  b}^  operation.  They  are  the  cases  in  which  a 
circumscribed  cyst  formation,  as  previously  described,  has  oc- 
curred, and  the  suppuration  is  due  to  a  mixed  infection.  These 
cysts  should  be  opened,  gently  cleansed,  mopped  out  with  weak 
formalin  solution,  and  closed.  Murphy  relates  an  extreme  case 
of  this  kind.  He  writes:  "In  one  of  my  cases  there  were 
no  intestines  except  the  descending  colon  and  the  rectum  below 
the  umbilicus,  a  firm  diaphragm  of  adhesions  having  formed 
across  the  abdomen  at  the  umbilical  level.  The  peritoneum 
above  this  diaphragm  was  free  from  tuberculosis ;  below  the  dia- 
phragm was  one  large  empyema  of  the  peritoneum.  After 
opening  and  draining  the  cavity,  this  wall  proved  so  dense  and 
firm  that  there  was  verv^  little  contraction  and  the  patient  suc- 
cumbed to  the  toxaemia  of  the  mixed  infection.  The  abdomen 
should  have  been  closed  after  the  exploration  and  repeatedly 
aspired  and  injected  with  a  solution  of  formalin-iodoform- 
glycerin." 

To  sum  up:    vSurgical  measures  should  be  adopted  only  in 


TUBERCULOUS    PERITONITIS.  I33 

those  cases  of  tuberculous  peritonitis  in  which  there  is  effusion 
of  fluid  into  the  general  peritoneal  cavity.  In  these  cases  a 
decided  benefit  results  from  the  operation;  the  immedate  effect 
is  often  remarkably  good,  and  the  number  of  cases  in  which  a 
permanently  satisfactory  result  is  obtained  is  probably  50  per 
cent,  of  the  whole.  The  fibrous  and  the  suppurative  forms  of 
peritonitis  are  rarely  suited  to  treatment  by  operation ;  opera- 
tion in  most  of  these  cases  almost  certainly  does  harm  rather 
than  good. 

It  is  certainly  desirable  that  operation  should  be  practised 
in  an  early  stage  of  the  disease,  or  at  least  should  not  be  postponed 
until  the  patient  has  become  so  wasted  and  exhausted  that  the 
shock  of  the  operation  is  likely  to  be  serious.  After  a  trial 
of  general  medical  treatment  for  three  to  six  months  after  the 
onset  of  a  fluid  effusion,  surgical  measures  should  certainly  be 
advocated. 

OPERATION. 

The  operative  treatment  of  tuberculous  peritonitis  is  due  to 
Spencer  Wells  who,  in  1862,  opened  the  abdomen  of  a  patient 
whom  he  supposed  to  be  suffering  from  an  ovarian  cyst.  Tu- 
berculous peritonitis  was  found  and  the  abdomen  was  closed. 
To  everyone's  surprise  the  patient  rapidly  improved  after  opera- 
tion, and  was  soon  cured  of  her  disease.  The  first  formal  advo- 
cacy of  laparotomy  as  a  therapeutic  measure  is,  however,  due 
to  Konig,  in  1884. 

The  surgical  indications  in  dealing  with  tuberculous  peri- 
tonitis by  operation  are,  as  stated  b}^  ]\Iurphy: 

1.  To  remove  or  shut  off  the  source  of  supph^  of  the  tuber- 

culous material ;  that  is,  to  remove  the  primary  focus 
of  the  disease. 

2.  To  remove  the  products  of  the  infective  process  from  the 

peritoneum. 

3.  To  increase  the  tissue  proliferation  for  the  encapsulation 

of  the  foci  already  present. 

4.  To  avoid  mixed  infection. 


134  ABDOMINAL   OPERATIONS. 

The  operation  in  the  ascitic  form  of  the  disease  is  of  the 
simplest  character:  The  abdomen  is  opened  in  the  middle  line 
below  the  umbilicus,  an  incision  of  about  four  inches  being 
made.  Care  is  necessary  when  the  parietal  peritoneum  is  being 
incised,  for  the  membrane  is  often  greatly  thickened,  and  a 
coil  of  intestine  may  chance  to  be  adherent  to  its  under  surface. 
As  soon  as  the  peritoneum  is  incised,  some  fluid  will  escape. 
The  fluid  should  be  emptied  as  completely  as  possible;  as  soon 
as  the  flow  from  the  wound  has  ceased,  the  edges  of  the  incision 
are  held  apart  and  a  sterile  gauze  swab  is  passed  into  the  pelvis 
and  into  the  kidney  pouches,  so  as  to  mop  up  any  fluid  that  lies 
there.  In  doing  this  all  rough  manipulation  must  be  avoided ; 
the  peritoneum  must  be  gently  patted  with  the  swab,  and  not 
rubbed  by  it.  Friction  will  only  start  a  slight  but  troublesome 
bleeding  from  many  points. 

In  these  manipulations  it  may  become  evident  that  the  ori- 
gin of  the  disease  lies  in  some  special  portion  of  the  abdominal 
contents  in  the  Fallopian  tube,  intestine  or  appendix.  If  the 
surgeon  feels  assured  of  this,  he  should  not  hesitate  to  remove 
the  source  of  offence,  for  a  complete  healing  of  the  disease  is 
then  more  likely  to  result.  Resection  of  a  diseased  part  of  the 
intestine  or  short-circuiting  may  therefore  be  necessary.  If 
the  patient  is  a  woman,  it  is  well  to  place  her  in  the  Trendelen- 
burg position  as  soon  as  the  fluid  is  emptied  away.  A  free 
examination  of  the  pelvic  organs  is  then  possible,  and  an  affected 
tube  or  tubes  can  be  at  once  removed.  In  cases  of  the  ascitic 
form  of  the  disease  an  operation  should  not  be  considered  com- 
plete which  leaves  unexamined  any  of  those  areas  which  are 
known  to  be  commonly  the  primary  sources  of  infection.  In 
women  undoubtedly  the  peritoneal  inflammation  is  secondary 
to  tubal  disease  in  a  very  large  number  of  cases,  and  in  all  such 
the  affected  tube  must  be  removed.  The  very  significant  patu- 
lous condition  of  the  fimbriated  opening  of  the  Fallopian  tube 
should  always  be  remembered.  As  Murphy  has  shewn,  it  in- 
dicates   invariably  the  presence    of   tuberculous    disease   within 


TUBERCULOSIS    PERITONITIS.  I35 

the  tube.  The  exposure  of  the  tube  and  its  removal  may  be 
extremely  difficult.  The  adhesions  are  so  complex,  the  adher- 
ent bowel  so  thin  and  friable,  that  the  utmost  care  is  needed  in 
detaching  the  tube.  It  may  be  that  the  anatomical  landmarks 
are  obliterated  in  a  bewildering  mesh  of  adhesions.  The  round 
ligament  must  then  be  sought  at  the  internal  abdominal  ring 
and  traced  backwards  to  the  uterus.  Little  by  little,  adhesions 
are  separated  with  the  utmost  gentleness,  until  the  tube  is  well 
exposed. 

The  cavity  being  rendered  as  dry  as  possible,  the  abdominal 
wound  is  closed  by  suture  in  the  usual  manner.  Drainage 
should  not  be  practised, — it  is  of  no  advantage,  and  it  is  not 
unlikely  to  do  harm  by  causing  adhesion  of  the  drainage  ma- 
terial to  a  piece  of  bowel  which  may  subsequently  give  way. 

Some  surgeons  advocate  the  introduction  into  the  abdomen 
of  iodoform;  others,  the  washing  out  of  the  peritoneal  cavity; 
others  again,  drainage  through  the  vagina  in  the  female.  All 
these  are  unnecessary.  Simple  opening,  emptying  and  closing 
of  the  abdomen,  with  removal  of  the  primary  focus,  are  all 
that  are  necessary  to  ensure  success;  and,  throughout,  the 
utmost  gentleness  is  needed. 

In  cases  of  all  kinds,  but  more  especially  in  those  where  the 
quantity  of  fluid  in  the  abdomen  is  small,  the  introduction  of 
warm  sterile  white  paraffin,  in  the  largest  quantities  possible,  is  a 
great  advantage  in  preventing  the  reformation  of  adhesions. 
Sterile  warm  oil  or  vaseline  may  also  be  used,  or  possibh^  the 
formaline-gelatine  solution  used  in  experimental  work  by  Archi- 
bald.    I  have  no  personal  experience  of  anything  but  paraffin. 

The  reason  for  the  success  of  simple  evacuation  of  the  fluid 
is  not  quite  clear.  On  the  whole,  the  explanation  given  b}^ 
Gatti  seems  the  most  reasonable.  He  believes  that  the  fluid 
poured  out  by  the  peritoneum  after  closure  of  the  wound,  like 
the  fluid  found  in  the  general  peritonium  when  a  localised  ap- 
pendicitis is  present,  is  actively  bactericidal,  and  that  it  exerts 
a  potent  deleterious  influence  upon  the  tubercle  bacillus.     It  is 


136  ABDOMINAL    OPERATIONS. 

certain  that  in  many  cases,  probably  in  all,  an  effusion  does 
occur  into  the  peritoneum  in  sufficient  quantit}^  to  be  easily 
recognised  on  palpation  and  percussion.  Hildebrandt  lays 
stress  upon  the  occurrence  of  postoperative  hyperaemia,  which 
causes  a  plastic  outpouring  around  the  tuberculous  nodules, 
resulting  in  their  fibrous  encapsulation.  This  is  a  method  of 
"cure"  constantly  seen  elsewhere. 

Murphy  writes:  "If  the  peritoneum  be  inspected  three  or 
foiu-  days  after  the  laparotomy,  as  I  have  had  opportunity  to  do 
on  more  than  one  occasion,  it  will  be  found  intensely  congested, 
its  A'ascularity  greatly  increased,  its  gloss  almost  or  quite  abol- 
ished, and  the  fluid,  not  fresh,  clear  serum,  but  cloudy  or  sero- 
punilent,  showing  the  most  active  proliferation.  It  is  this 
tissue  proliferation  which  overwhelms  and  encapsulates  the 
tubercular  foci  on  the  surface  of  the  peritoneum."  If  the 
primar}'  focus  is  the  tube,  removal  of  the  fluid  allows  the  open 
tube  to  fall  against  the  peritoneum,  to  contract  adhesions,  and 
at  last  to  become  seciu-eh'  walled  off  from  the  general  peritoneum. 
Here,  as  in  so  many  other  parts,  the  "cure"  of  tuberculous  areas 
means  the  encapsulation  of  the  bacilli  in  the  firm  grasp  of  newly 
formed  fibrous  tissue. 

[I  would  refer  readers  interested  in  this  subject  to  two  ex- 
tremely valuable  papers,  Dr.  J.  B.  Murphy's  "Tuberculosis  of 
the  Female  Genitalia, "  and  Dr.  AV.  J.  ]\Iayo"s  article  in  the  "Jour- 
nal of  the  American  ^Medical  Association,"  April  15,   1905.] 


CHAPTER  VIII. 

SUBPHRENIC  ABSCESS. 

An  abscess  beneath  the  diaphragm,  between  it  and  the 
Hver,  may  be  either  intraperitoneal  or  extraperitoneal ;  it 
may  lie  to  the  right  or  to  the  left  of  the  suspensory  ligament 
of  the  liver.  The  intraperitoneal  form  is  decidedly  more  fre- 
quent than  the  extraperitoneal,  and  the  abscess  is  more  com- 
monly found  upon  the  right  side. 


Fig.  28. — Subphrenic  abscess  (riglit  side). 

The  upper  and  posterior  surfaces  of  the  liver  are  partly 
covered  by  peritoneum,  partly  devoid  of  any  serous  covering. 
The  suspensory  ligament  forms  an  oblique  partition,  divid- 
ing the  liver  into  a  larger  right,  and  smaller  left,  portion. 

An  abscess  which  lies  to  the  right  of  the  falciform  liga- 
ment begins  generally  in  inflammation  affecting  the  gall-blad- 
der, the  liver,  the  kidney,  or  the  appendix.  An  abscess 
which  lies  to  the  left  of  this  ligament  starts,  in  the  majority 


138  ABDOMIXAL  OPERATIONS. 

of  cases,  from  a  perforating  ulcer  of  the  stomach  or  duo- 
denum, or  from  inflammation  in  the  pancreas,  intestines, 
spleen,  or  left  kidney.  The  commonest  source  of  infection  I 
formerlv  believed  to  be  the  appendix,  but  recent  statistics  do  not 
support  this  view.     Korte  reported  a   series   of   60  cases  upon 


Fig.  29. — Subphrenic  abscess  (left  side). 


which  he  had  operated,  40  patients  recovering.  The  origin  of 
the  abscess  was  in  the  appendix  in  2  7  cases ;  in  the  stomach  in 
9;  the  duodenum  in  i;  the  spleen  in  5.  He  gives  the  follow- 
ing statement : 

Source  of  Abscess.                          XuiiBER  of  Cases.     Recox-ered.  Died. 

Appendix 27                       18  q 

Stomach 9                        5  4 

Duodenum i                         o  1 

Spleen 5                        3  2 

Kidney 4                        2  2 

Liver  and  gall-bladder 2                        2  o 

Pleura 4                        3  1 

Costal 2                         2  o 

Pancreas i                        i  o 

Hydatid 3                         3  o 

Undetermined 2                          i  i 

60                       40  20 


SUBPHRENIC   ABSCESS.  1 39 

Perutz  ("Cent.  f.  d.  Grenzgebiet.  der  ]\Ied.  und  Chir.,"  1905, 
Nos.  4  to  10,  inclusive)  has  collected  the  records  of  208  cases. 
He  gives  the  following  table  to  shew  the  starting-point  in  his 
own  series  of  cases,  and  in  IMa^^dl's  and  Korte's: 

In  Perutz's  In  Maydl's  In  Korte's 

Series  Series  Series 

Stomach 67  35  9 

Duodenum 3  8  i 

Appendix 55  25  27 

Liver  and  bile  passages 17  20  2 

Hydatid 5  17  3 

Intestine 7  5  o 

Pancreas 4  o  i 

Spleen • 4  o  5 

Kidney 7  ir  4 

Ribs I  3  2 

Intrathoracic 8  9  4 

Female  generative  organs 6  o  o 

Traumatic 8  6  o 

Metastatic 5  11  o 

Various  and  unknown ; 11  11  2 

Total 208  179  60 

E.  R.  Hunt  ("Lancet,"  Dec.  17,  1904,  p.  1718)  reports  38  cases 
of  subphrenic  abscess  occurring  at  St.  Mary's  Hospital.  In 
19  cases  the  primary  lesion  was  situated  in  the  stomach.  The 
other  probable  causes  were :  duodenal  ulcer  in  3 ;  hepatic  ab- 
scess in  4 ;  appendicitis  in  3 ;  perityphlitis  in  4 ;  malignant 
disease  of  the  stomach  in  2 ;  renal  calculus  in  i ;  splenic  ab- 
scess in  I ;  and  injury  in  i .  Left-sided  subphrenic  abscesses 
were  met  with  more  frequently  than  right-sided,  and  in  only 
I  of  the  19  cases  consequent  upon  gastric  ulcer  did  right-sided 
abscess  occur. 

"The  pus  was  situated  between  the  left  lobe  of  the  liver, 
the  diaphragm,  and  the  spleen.  Sometimes  the  pus  was  situ- 
ated to  the  left  of  the  spleen,  between  that  organ  and  the 
diaphragm.  Of  this  group  there  were  seven  examples,  all 
due  to  perforation  through  the  posterior  wall  of  the  stomach. 
More  rarely  the  abscess  might  be  in  front  of  the  stomach 
and  liver,  being  bounded  in  front  by  the  diaphragm  and  ab- 


140 


ABDOMINAL   OPER.\TIONS. 


dominal  wall  and  behind  b}^  the  left  lobe  of  the  liver  and  the 
stomach;  of  this  group  there  were  three  examples.  Right- 
sided  subphrenic  abscesses  were  nearly  always  situated  be- 
tween the  liver  and  the  diaphragm,  their  spreading  left  and 
right  being  prevented  b}^  the  falciform  ligament  and  the  tho- 
racic wall.  They  tended  to  extend  downwards  and  backwards 
in  a  large  number  of  instances,  not  infrequently  reaching  as 
far  as  the  right  kidnev." 


Fig.  30. — Subphrenic  abscess  in  front 
of  the  liver. 


Fig.  31. — Subphrenic  abscess  in  the 
lesser  sac. 


The  inflammation  from  the  appendix  may  spread  up- 
wards, within  the  peritoneal  cavit^^  along  the  outer  side  of 
the  colon,  in  the  manner  already  described,  or  it  may  pass 
upwards  in  the  loose  cellular  tissue  behind  the  colon. 

When  an  ulcer  of  the  stomach  destroys,  by  slow  degrees, 
the  entire  thickness  of  the  wall,  a  ''chronic  perforation'' 
occurs  and  a  perigastric  abscess  results.  In  many  cases  this 
abscess  lies  immediately  beneath   the   diaphragm. 


SUBPHRENIC   ABSCESS. 


141 


Disease  of  the  gall-bladder,  bile-ducts,  and  intrahepatic 
ducts  may  all  lead  to  diffuse  suppuration  between  the  liver 
and  the  diaphragm.  Abscesses,  at  first  within  the  substance 
of  the  liver,  may,  in  a  later  stage,  and  in  their  gradual 
enlargement,  burst  through  the  bounds  of  the  liver  and  be- 
come subphrenic. 

In  the  majority  of  cases  a  subphrenic  abscess  contains 
gas,  which  is  derived,  as  a  rule,  from  the  action  of  gas-form- 
ing bacteria,  but  may  also  come 
from  a  hollow  viscus.  For  this  reason 
gas  is  more  often  found  to  be  pres- 
ent in  an  abscess  on  the  left  side 
than  in  one  on  the  right. 

The  diagnosis  of  subphrenic  ab- 
scess is  often  difficult,  especially  if 
there  be  no  free  gas  within  the  cav- 
ity. When  there  is  fluid,  serous  or 
purulent,  at  the  base  of  the  right 
lung,  this  difficulty  is  considerably 
enhanced.  The  physical  signs  that 
may  be  elicited  are  the  following: 

On  the  right  side  posteriorly 
there  will  be  dulness  at  the  base  of 
the  chest.  If  there  be  no  free  gas 
within  the  abscess,  the  liver  dulness 
will  merge  above  into  the  dulness 
produced  by  the  overlying  pus.  The 
upper  edge  of  this  dull  area  will  be  convex.  The  physical 
signs  are,  therefore,  the  same,  in  such  a  case,  as  in  a  case  of 
abscess  of  the  liver.  When,  however,  gas  is  present  within 
the  abscess,  the  signs  are  most  characteristic.  Percussion 
reveals  three  zones  of  different  resonance,  one  above  the 
other.  The  upper  is  the  normal  resonance  of  the  lung ;  in  the 
middle  there  is  the  tympany  due  to  the  gas  within  the 
abscess;    in  the    lower,   the    dulness    due    to    the   fluid    within 


Fig. 


32. — Subphrenic  abscess; 
retroperitoneal. 


142  ABDOMINAL   OPERATIONS. 

the  abscess;  this  latter  dulness  merges  into  the  dulness  of 
the    Hver. 

Abscesses  on  the  left  side,  coming  as  they  do  from  the 
stomach  or  duodenum,  contain  gas;  the  physical  signs,  there- 
fore, are    generally  those  which  have  just  been  described. 

When  pleuritic  effusion  is  present  above  the  subphrenic 
abscess,  four  zones  of  var^dng  resonance  may  be  encountered. 
The  topmost  is  the  normal  resonance ;  the  next  is  a  dulness 
due  to  the  pleuritic  fluid;  the  next,  a  tympany  due  to  the 
gas  of  the  abscess;  and,  lowest  of  all,  a  dull  area  due  to  the 
pus  in  the  abscess  cavity. 

An  abscess  on  the  right  side  may  push  the  liver  down- 
wards. On  both  sides  a  bulging  of  the  chest-wall  or  of  the 
anterior  abdominal  wall  may  be  seen. 

The  diagnosis  in  all  cases  must  be  verified  by  the  exami- 
nation of  the  chest  with  an  exploring  needle  of  fair  size  and 
of  good  length.  As  a  rule,  the  most  sensitive  part  of  the  dull 
area  is  selected  for  the  introduction  of  the  needle;  repeated 
introduction  of  the  needle  may  be  necessar\^,  for  the  pus  is 
often  thick  and  will  not  run  easily  through  even  a  stout 
needle.  In  some  cases  there  is  a  thick,  tenacious  layer  of 
lymph  on  the  upper  surface  of  the  liver,  and  this  blocks  the 
needle  instantly. 

The  frequency  of  the  association  of  pleural  complications  in 
cases  of  subphrenic  abscess  can  only  be  gauged  with  certainty 
in  cases  which  are  operated  upon  b}'  the  transpleural  method,  or 
in  those  fatal  ones  where  a  postmortem  examination  is  made. 
In  Korte's  series  of  60  cases  (reported  by  Gruneisen)  pleural 
complications  were  found  in  40.  In  Perutz's  series  of  208  cases 
it  is  noted  that  pleural  affections  were  observed  in  55,  but  in 
many  cases  the  abscess  was  opened  by  median  or  lateral  abdom- 
inal incision.  In  some  no  operation  was  performed;  in  some 
the  clinical  record  is  brief.  Korte  makes  the  interesting  observa- 
tion that  in  the  cases  where  he  performed  a  transpleural  opera- 
tion the  pleura  ''was  seldom  free  from  disease." 


SUBPHRENIC   ABSCESS.  1 43 

OPERATION. 

Subphrenic  abscesses  may  be  opened  in  one  of  four  ways: 

1.  By  incision  through  the   anterior  abdominal  wall. 

2.  By  incision  along  the  lower  costal  margin. 

3.  By  incision  through  the  chest-wall  and  diaphragm. 

4.  By    a    combination    of    the    thoracic    and    abdom- 

inal incisions. 

1.  Incision  through  the  anterior  abdominal  wall  is  suited 
to  those  cases  of  large  abscess  which  bulge  forward  in  the  epi- 
gastrium. These  are,  almost  without  exception,  due  to  per- 
foration of  the  stomach. 

The  abdomen  having  been  opened,  the  abscess  is  reached, 
and  its  contents,  often  of  amazing  offensiveness,  are  evacu- 
ated. After  the  gas  and  much  fluid  have  escaped,  a  pool  of 
pus  will  be  found  to  lie  far  back  in  the  cavity.  This  must  be 
m.opped  up  with  swabs  and  the  posterior  limit  of  the  cavity 
defined.  It  will  then  generally  be  found  necessary  to  make 
a  counter-opening  into  the  abscess  from  the  loin  in  order 
to  ensure  efficient  drainage.  Both  anterior  and  posterior 
wounds  are  drained.  I  have  found  the  split  rubber  drain,  of  a 
diameter  of  an  inch  and  a  half,  the  best  of  all  forms  to  use. 
The  cavity  may,  if  thought  desirable,  be  w^ashed  out  with  hot 
saline  solution  or  with  a  solution  of  peroxide  of  hydrogen. 

2.  The  incision  along  the  costal  margin  is  carried  through 
all  the  muscles  of  the  abdominal  wall.  The  further  deepen- 
ing of  the  wound  is  accomplished  with  great  care,  by  blunt 
dissection  with  the  finger,  until  the  limits  of  the  abscess  are 
reached.  A  small  opening  is  then  made  into  the  cavity  and 
gradually  enlarged  in  the  direction  in  which  it  is  clear  that 
no  harm  can  be  done.  This  method  is  advocated  by  von 
Mikulicz  for  extraperitoneal  abscesses  on  the  right  side. 

3.  The  transpleural  operation  is  that  most  often  employed. 
An  incision,  five  or  six  inches  in  length,  is  made  over  the 


144  ABDOMINAL   OPERATIONS. 

ninth  or  tenth  ribs,  on  the  right  side,  and  over  the  seventh 
or  eighth  on  the  left  side,  the  middle  of  the  incision  being  at 
the  point  from  which  pus  has  been  withdrawn  by  the  explor- 
ing needle.  The  ribs  are  exposed,  and  about  3I  or  4  inches 
of  each  are  excised.  The  condition  of  the  pleural  cavity  is 
then  determined.  If  it  is  empty  or  contains  onty  clear  fluid 
in  small  quantity,  it  must  be  protected  from  infection,  either 
by  packing  the  wound  tightly  with  gauze  and  postponing  the 
completion  of  the  operation  for  twenty -four  hours,  or  by  the 
introduction  of  stitches  which  include  the  diaphragm,  both 
layers  of  the  pleura,  and  the  chest-wall.  After  the  stitches 
have  been  passed,  a  little  gauze  packing  is  pressed  around 
the  edges  of  the  wound  so  as  to  form  a  sort  of  barrier.  The 
diaphragm  is  then  incised,  the  cut  edges  seized  with  forceps 
and  drawn  forwards  (this  is  generally  easily  accomplished  as 
the  diaphragm  is  pushed  well  upwards  by  the  abscess  beneath 
it),  and  the  cavity  emptied,  washed  out  gently,  and  drained 
with  a  large  cigarette  drainage-tube. 

4.  A  combination  of  the  thoracic  and  abdominal  incisions 
is  in  some  instances  an  advantage  in  that  it  secures  a  more 
certain  drainage.  The  thoracic  incision  is  carried  on  to  the 
abdomen,  and  the  cavity  above  the  liver  freely  opened.  An 
abundant  supply  of  gauze  is  introduced  into  the  cavity  and 
frequently  removed  in  order  to  ensure  free  drainage  and  a 
speedy  healing. 

Perutz  gives  the  following  tabular  statement  of  the  results  of 
cases  treated  by  operation  in  the  three  series  already  mentioned : 


SUBPHRENIC   ABSCESS. 
TABLE  OF  CASES  TREATED  BY  OPERATION. 


145 


Stomach 

Duodenum 

Appendix 

Liver  and  bile  passages 

Hydatid 

Intestine 

Pancreas , 

Spleen 

Kidney 

Ribs 

Intrathoracic 

Female  organs 

Traumatic 

Metastatic 

Various  and  unknown. 

Total 


In  Perutz's 
Series 


47 

I 

40 

12 

4 
6 

3 
3 
6 

I 
6 
S 
7 
S 
9 


IS5 


33 
o 

30 
II 

3 


14 


116 


In  Maydl's 

Series 


39 


14 

5 

14 


In  Korte's 
Series 


74 


39 


35 


60 


9 

5 

I 

0 

27 

18 

2 

2 

3 

3 

0 

I 

I 

40 


The  two  most  striking  facts  brought  out  by  this  table  are  the 
diminution  in  the  mortaHty  during  the  last  few  years,  and  the 
small  mortality  in  those  cases  where  the  abscess  depended  upon 
diseases  of  the  liver-  or  bile-passages.  The  cases  in  Maydl's 
series  were  treated  up  to  the  year  1894,  in  Perutz's  series  from 
1894  to  1904.  The  mortality  in  the  first  series  was  48  per  cent.; 
in  the  second  26  per  cent. 

Perutz  also  analyses  the  53  cases  in  which  no  operation  was 
performed.  Of  these  44  died  and  9  recovered,  a  mortality  of 
about  85  per  cent.  In  Maydl's  unoperated  cases,  104  in  number, 
there  were  98  deaths. 

H.  L.  Barnard  ("Brit.  Med.  Jour.,"  1908,  i,  pp.  371,  429) 
has  analysed  76  consecutive  cases  of  subphrenic  abscess  and  has 
written  an  exhaustive  paper  on  their  incidence,  etiology,  path- 
ology, anatomical  relationships,  and  treatment.  He  classifies 
the  subphrenic  fossae  as  follows : 

Right  anterior. 

Right  posterior. 

Left  anterior. 

Left  posterior. 

Right. 

Left.     ■ 


Intraperitoneal 


Intraperitoneal 


146 


ABDOMINAL   OPERATIONS. 


The  division  of  these  spaces  being  made  by  the  coronan^  falci- 
form, and  the  right  and  left  hepatic  ligaments.  The  falciform 
ligament  divides  the  subphrenic  space  into  right  and  left  com- 
partments ;  each  of  these  being  again  subdivided  into  a  larger  an- 
terior and  a  smaller  posterior  part  by  the  corresponding  lateral 
ligament.  The  right  extraperitoneal  subphrenic  space  lies  be- 
tween the  layers  of  the  coronary  ligament  and  is  really  only  a 
potential  space.  The  left  extraperitoneal  subphrenic  space  is  in 
the  neighbourhood  of  the  upper  pole  of  the  left  kidney.  The  fol- 
lowing is  an  anatysis  of  Barnard's  cases. 

ANALYSIS  OF    CASES. 
Anatomical  Varieties. 


A.  IXTRAPERITOXEAL. 

I.  Right: 

(a)  Anterior 

(b)  Posterior ...... 

IL  Left: 

(a)  Anterior 

(b)  Posterior 

B.  Extraperitoneal. 
I.  Right 

II.  Left 

Not  classified.  .  .  . 


No.  OF  Cases. 


3° 


19 
4 


Simple. 


13 
4 


Compound. 


16 


Simple  =  One  cavity  only  involved. 
Compound  =  Two  or  more  cavities  involved. 

Anatomical  Varieties  According  to   Causes. 


Anatomical  Variety.                      Ulcer'*^       Appendicitis. 

Hepatic          Duodenal 
Abscesses.          Ulcer. 

Intraperitoneal  right  anterior  .  .             4                    10 
Intraperitoneal  right  posterior.  .              i                      6 
Intraperitoneal  left  anterior.  ..  .            16                      i 
Intraperitoneal  left  posterior  .  .              2                      0 

Extraperitoneal  right 0                      j 

Extraperitoneal  left i                      0 

7                      I 
I                      2 
I                       I 
0                      0 
15                      2 

Etiolo(;s". 

Cases. 

Gastric  ulcer 21 

Gastric  cancer 2 

Appendicitis 12 

Liver:  Suppurating  hydatid 8 

Liver:  Tropical  abscess 6 


SUBPHRENIC   ABSCESS.  I47 

Cases. 

Liver :  Abscess i 

Pylephlebitis i 

Suppurative  cholansjitis i 

Duodenal  ulcer  (anterior) 3 

Duodenal  ulcer  (posterior) 2 

Splenic  abscess 3 

Pya?mia 3 

Parturition 3 

Thoracic  pneumonia i 

Thoracic  bronchiectasis i 

Thoracic  empyema i 

Periostitis  of  vertebras 2 

Operations,  resections 2 

Pancreas  cancer i 

Kidney  cystic i 

Intestine  ruptured i 

Typhoid i 

Gall  stones i 

Pyosalpinx i 

No  cause  found 2 


Age  of 

75  Cases  of  Subphrenic  Abscess  Arranged  in  Decades. 

Age 

0— 10 

10—20    20—30    30—40    40—50    50—60  1  60—70 

Cases 

6 

5          29     :     15 

13          ^     \     ^- 

Sex  of   76   Cases  of  Subphrenic 

Abscess. 

Cases. 

Per  Cent. 

Male 

43 

33 

76 

56.6 

43-4 

100 

Female.  .  .  . 
Total 

The  Spontaneous  Rupture  of  23   Cases  of   76  Subphrenic 

Abscesses. 

Into —  Cases. 

A  bronchus 4 

The  pleura,  right 2 

The  pleura,  left 3 

The  general  peritoneum i 

The  stomach 8 

The  intestine i 

The  colon 2 

The  skin  (a)  umbilicus i 

(6)  right  hypochondrium i 

23 


148  ABDOMINAL   OPERATIONS. 

Micro-organisms  Found  in  Pus  of  Subphrenic  Abscesses. 

Cases. 

Number  examined 12 

Sterile 3 

B.  coli  communis 3 

Staphylococcus  aureus .2 

Streptococcus i 

Pneumococcus i 

B.  pyocyaneus i 

B.  typhosus I 

Onset  in   76   Cases  of  Subphrenic  Abscesses. 

Acute 40  cases  =  62.6  per  cent. 

Subacute  \ ^^  cases  =  47.4  per  cent. 

Chronic    J 

Gastric  ulcer  (21  cases): 

Acute " 15 

Subacute "[  ^ 

Chronic    / 
Gastric  cancer  (2  cases): 

Acute o 

Subacute  1 

I 2 

Chronic    / 

Appendicitis  (12  cases): 

Acute 12 

Subacute ) 

Chronic    /  ' 
Hydatid  of  liver  (8  cases) : 

Acute 2 

Subacute  "(^  ^ 

Chronic    / 
Hepatic  abscesses  (7  cases): 

Acute I 

Subacute |  ^ 

Chronic    / 
Duodenal  ulcer  (5  cases) 

Anterior  (  =  Acute) 3 

Posterior  (  =  Subacute) 2 

Splenic  abscess  (3  cases) : 

Subacute 3 


The  Sig.mificance  of  Rigors  in  Subphrenic  Abscesses 

Cases. 

Number  recorded • 10 

Died 6 

Pyaemias  (2  chronic  ones  lived) 5 

Communicated  with  .stomach 2 

Suppurative  cholangitis i 

Acute  periostitis i 


SUBPHRENIC   ABSCESS.  I49 

The   Use  of  the  Aspirating  Needle  in  Eighteen    Cases  of  Subphrenic 
Abscesses.     Some  Several  Times. 

Cases 

Failed  to  diagnose 11 

Pus 7 

Foul  pus 2 

Anchovy  pus i 

Pus  and  serum i 

Clear  serum 4 

Blood-stained  serum 2 

Gas 2 

Mortality  of   76   Cases  of  Subphrenic  x\bscess. 

Deaths.  Per  Cent. 

76  cases 36  =  47.4 

12  cases  no  operation 12  =        100. o 

64  cases  operated  on 24  =  37.0 

21  cases  operated  on  by  author 4  =  19.0 

Analysis  of  36  Deaths. 
(A)   Unavoidable. — 12  deaths  =  16  per  cent,  (about). 

Multiple  abscesses  of  liver 5  cases 

Cancers 2 

Hour-glass  stomach 2      " 

Lung  complications 2      " 

General  peritonitis i  case 

(B)  Avoidable  (probably). — 24  deaths. 

Not  operated  on 12  cases 

Anterior  operation;  other  pouches  left 8 

Transpleural  operation  in  dififuse  stage 2 

General  peritoneum  opened  by  anterior  incision i  case 

Inefficient  needling i      " 

The  Ideal  Mortality  of  Subphrenic  Abscess  =  about  16  per  cent. 


/ 


CHAPTER  IX. 

THE  SURGICAL  TREATMENT  OF  VISCERAL  PROLAPSE. 

The  Surgical  Treatment  of  Gastroptosis. 

Gastroptosis  is  a  disease,  the  frequency  and  significance 
of  which  are  variously  estimated  by  different  writers.  Glen- 
ard  found  a  condition  of  enteroptosis  in  400  out  of  1300  pa- 
tients, and  has  given  us  the  most  complete  description  of  the 
disease  which  has  been  published. 

The  circumstances  which  are  present  are  these:  There  is 
a  weakening  of  all  the  natural  supports  of  the  viscera;  the 
peritoneal  ligaments  are  long,  lax,  and  unequal  to  their  bur- 
den, and  the  abdominal  wall  in  its  lower  part  is  pushed  for- 
wards, bulging  in  characteristic  fashion;  a  passive  dilatation 
of  any  parts,  or  of  all  parts,  of  the  alimentary  canal  may  be 
present. 

The  patient  complains  chiefly  of  a  sense  of  a  heavy 
weight,  of  dragging,  and  of  weariness  in  the  abdomen.  There 
is  often  nausea,  and  sometimes  vomiting;  there  are  fulness, 
flatulence,  eructations.  The  bowels  act  irregularly,  and  con- 
stipation is  always  a  prominent  feature.  The  patient  is 
almost  always  a  neurasthenic  of  a  most  pronounced  type. 

An  examination  will  disclose  the  circumstances  men- 
tioned above — a  laxity  of  the  supports  and  consequently  an 
undue  mobility  of  all  the  organs  in  the  abdomen. 

In  the  great  majority  of  cases  relief  is  aft'orded  by  the  wear- 
ing of  an  abdominal  belt.  In  some  cases,  however,  the  wearing 
of  a  belt  has  proved  ineffective  and  resort  has  been  had  to  sur- 
gery.    The  operation  practised  is  known  as  "  gastropexy. " 

Buret's  Operation.  —It  is  to  Duret,  of  Lille  ("  Revue  de  Chir.,  " 
1896,  p.  430J,  that  we  owe  the  first  suggestion  for  the  performance 

350 


SURGICAL   TREATMENT   OF   VISCERAL   PROLAPSE. 


LSI 


of  the  operation  of  "gastropexy.  "  His  patient  was  a  married 
woman  who  had  suffered  very  severely  for  three  years  from  gas- 
troptosis.  The  method  adopted  for  the  purpose  of  fixing  the 
stomach  up  to  the  abdominal  w^all  in  approximately  its  proper  po- 
sition was  as  follows :  A  long  incision  was  made  in  the  abdominal 
wall  from  the  xiphoid  cartilage  to  the  umbilicus  dow^n  to  the 
peritoneum.  The  peritoneum  in  the  upper  part  of  the  wound 
was   not   incised,    but   was   bared   on   its   anterior   surface   bv 


Fig.   ^T,. — Gastropexy;  Buret's  operation. 

stripping  away  the  recti  from  it.  The  abdomen  was  opened 
through  the  lower  part  of  the  peritoneum.  The  stomach  was 
then  sought.  Through  the  stomach  and  the  undivided  peri- 
toneum in  the  upper  half  of  the  wound  a  suture  was  passed. 
The  suture  was  of  silk  and  was  continuous;  it  was  passed  at 
first  through  the  left  edge  of  the  parietal  incision,  through 
fasci,  rectus  muscle,  and  peritoneum,  and  then  horizontally 
through  the  serous  and  muscular  coats  of  the  stomach,  close 
to    the    lesser    curvature.     The    needle   was    now   passed   from 


I.S2 


ABDOMINAL   OPERATIONS. 


within  outwards  through  the  uncut  peritoneum,  and  then 
back  into  the  abdomen,  again  to  pick  up  the  stomach  as 
before.  A  series  of  loops  of  this  suture  were  then  taken.  As 
soon  as  the  stitch  was  tightened  the  stomach  was  slung 
upwards  and  there  fixed.     The  patient  did  well,  was  relieved  of 


Fig.  34. — Gastropex}^;    Rovsing's  operation.     The  area  between  the  stitches  is 
scarified  with  the  intention  of  promoting  firmer  adhesions. 


her  \-ery  distressing  s^^mptoms,  and  in  two  years  had  gained 
25   pounds  in  weight. 

A  similar  operation  to  this  was  performed  by  Davis,  but 
in  place  of  the  stomach  the  lesser  omentum  above  the  stom- 
ach was  picked  up  by  the  stitch. 

Rovsing's    Operation.  —  Rovsing,    of   Copenhagen,    has   per- 


Fig-  35- — Gastropexy;    Coffey's  operation.     The  suture  of  the  omentum  to  the 
anterior  abdominal  wall. 


Fig.  36. — Gastropexy;    Coffey's  operation.      The  suture  of  the  omentum  to  the 
anterior  abdominal  wall. 

153 


154  ABDOMINAL  OPERATIONS. 

formed  a  large  number  of  operations  by  a  method  of  his  own. 
The  method  consists  in  passing  three  stout  sutures  of  silk  trans- 
versely through  the  stomach,  picking  up  only  the  outer  coats. 
At  each  end  the  silk  is  tied  over  a  glass  rod,  after  being  taken 
through  all  the  layers  of  the  abdominal  wall.  The  stitches  are 
removed  at  the  end  of  four  weeks,  when  the  stomach  is  "solidly 
fixed"  to  the  anterior  abdominal  wall. 

Rovsing  describes  two  forms  of  gastroptosis :  (i)  That 
which  he  describes  as  "virginal,"  which  is  the  rarer  but  which 
is  the  more  important,  since  the  very  great  majority  of  the 
cases  needing  operation  belong  to  this  class.  The  abdominal 
wall  is  firm  and  strong.  (2)  That  which  occurs  in  multiparous 
women ;  it  is  often  accompanied  by  considerable  prolapse  of  other 
viscera,  causes  little  pain,  and  is  often  relieved  by  well-fitting 
bandages. 

Bandages  are  of  no  value  in  the  "virginal"  form  because  the 
abdominal  wall,  being  sound,  does  not  allow  adequate,  properly 
directed  pressure  to  be  exerted  by  any  external  appliance. 

Rovsing  has  operated  upon  49  cases;  44  belonged  to  the 
"virginal"  class,  5  to  the  "multiparous."  In  only  6  of  the 
cases  was  there  gastric  stasis.  All  the  patients  recovered  from 
the  operation  and  all  were  relieved,  with  the  exception  of  one 
case  where  there  was  also  a  narrowing  (unnoticed  at  the  time) 
of  the  duodenum  due  to  old  adhesions.  In  one  case,  gastropexy 
was  combined  with  hepatopexy;  in  another,  removal  of  the 
extremity  of  an  enlarged  left  lobe  of  the  liver  was  also  performed. 

Clarence  Webster,  in  cases  associated  with  divagation  of 
the  recti,  remedied  this  condition  by  resection  of  the  fascia 
and  approximation  of  the  muscles. 

Depage  in  1893  advocated  a  shortening  and  tightening  of  the 
abdominal  wall  in  all  its  diameters  by  an  extensive  plastic  opera- 
tion. The  operation,  however,  is  a  formidable  one.  Further 
objections  are  that  the  ligaments  are  not  shortened  and  a  second 
stretching  of  the  abdominal  wall  may  ensue. 

Coffey's  Operation. — -Coffey  supports  the  stomach  by  suturing 


SURGICAL   TREATMENT   OF   VISCERAL    PROLAPSE.  1 55 


v^- 


/ 


^ 


Fig.    37. — Beyea's  operation   for  gastroptosis — the   first   layer  of  sutures. 


Fig.   3S. — Beyea's  operation  for  gastroptosis — the  first  layer  of  sutures  com- 
pleted;   the  second  and  third  being  introduced. 


156  ABDOMINAL   OPERATIOXS. 

the  omentum  along  the  greater  curvature  to  the  abdominal  wall, 
above  the  umbilicus. 

Beyea's  Operation. — The  most  satisfactory  method  is  probably 
that  suggested  by  Beyea  ("Philadelphia  Med.  Jour..'"  Februan^, 
r 903 ,  p.  257).    The  operation  is  described  in  the  following  manner : 

"An  incision,  about  three  inches  in  length,  was  made  through 
the  linea  alba,  midway  between  the  xiphoid  cartilage  and  um- 
bilicus. The  tissues  were  separated  in  the  usual  manner  and 
the  peritoneal  cavity  opened,  exposing  a  small  portion  of  the 
lesser  curvature  and  cardiac  end  of  the  stomach,  the  gastro- 
hepatic  ligament  or  omentum,  gastrophrenic  ligament,  and  the 
lower  portion  of  the  left  lobe  of  the  liver.  The  table  was  then 
elevated  to  the  Trendelenburg  position,  and  the  stomach  displaced 
still  further  downwards  and  out  of  the  wound  by  means  of 
gauze  sponges.  This  procedure  caused  the  gastrohepatic  and  gas- 
trophrenic ligaments  to  be  slightly  stretched  and  separated  from 
the  underlying  structures,  which  permitted  an  accurate  deter- 
mination of  the  length  of  these  ligaments  and  very  much  facil- 
itated operative  manipulations.  The  gastrophrenic  ligament 
was  seen  well  developed,  and  evidently  formed  a  strong  support 
to  the  cardiac  end  of  the  stomach.  The  joining  portion  of  the 
gastrohepatic  ligament  was  composed  of  thin,  delicate  perito- 
neum, increasing  in  thickness  and  strength  towards  the  right 
or  pyloric  end  of  the  stomach.  Retractors  were  introduced  and 
the  liA'er  held  aside  by  placing  a  gauze  sponge  beneath  a  retrac- 
tor. Three  rows  of  interrupted  silk  sutures  were  then  intro- 
duced so  as  to  plicate  and  thus  shorten  the  gastrohepatic  and 
gastrophrenic  ligaments  in  the  following  manner :  The  first  row, 
beginning  in  the  gastrophrenic  ligament  and  extending  across 
the  gastrohepatic  ligament  to  almost  opposite  the  pyloric  ori- 
fice and  hepaticoduodenal  ligament,  was  introduced  so  as  to  form 
a  plication  in  the  centre  of  these  ligaments,  and  included  from 
above  downward  or  vertically  about  4  cm.  of  tissue  (row  No.  i). 
They  were  practically  mattress  sutures,  including  sufficient  of 
the  delicate  tissue  (i  cm.)  to  ensure  against  their  tearing  out. 
Five  sutures,  about  one  inch  apart,  were  introduced  from  right 
to  left,  and  caught  in  haemostatic  forceps.  The  next  row  (row 
No.  2)  of  sutures  was  introduced  in  the  same  manner,  but 
2.^   cm.  above  and  below  the  first    two.     Then    a    third   row 


SURGICAL   TREATMENT   OF   VISCERAL    PROLAPSE.  1 57 

(row  No.  3)  was  introduced  just  above  the  gastric  vessels  and 
a  short  distance  below  the  diaphragm  and  liver.  The  sutur- 
ing was  strictly  confined  to  the  normal  ligamentary  supports, 
and  the  distance  between  the  rows  from  left  to  right  was  in- 
creased with  the  length  of  the  ligaments,  being  greater  towards 
the  right.  The  gauze  sponges  were  then  removed,  and  the  first, 
the  second,  and  finally  the  third  row  of  sutures  were  secured, 
the  stomach,  particularly  the  pyloric  end,  being  elevated  to  a 
little  above  the  normal  position." 

The  sutures  were  of  silk.  Four  successful  cases  are  re- 
corded. A  similar  operation  has  been  performed  by  Bier.  In  a 
recent  letter  Dr.  Beyea  kindly  informs  me  that  he  has  oper- 
ated in  eight  cases,  with  marked  benefit  in  all.  The  first  case 
remains  well  after  about  eight  years.  I  have  only  once  per- 
formed the  operation,  and  the  result  has  been  very  good. 

The  advantage  of  the  operation  just  described  is  that  it 
does  not  solder  the  stomach  to  the  anterior  abdominal  wall, 
and,  therefore,  does  not  interfere  with  the  proper  mobility  of 
the  organ. 

There  are,  doubtless,  cases  in  which  an  operation  of  this 
kind  is  necessary.  Such  cases,  however,  are  few.  The  treat- 
ment by  external  mechanical  supports  should  always  be  given 
a  long  trial  before  surgical  measures  are  advocated,  and  con- 
sideration must  always  be  given  to  the  fact  that  the  patients 
are  often  of  a  profound  neurotic  type. 


Hepatoptosis. 

By  hepatoptosis  is  understood  that  condition  of  prolapse 
or  dropping  of  the  liver  due  to  the  inadequacy  of  the  suspen- 
sory^ apparatus.  A  mere  depression  of  the  liver  by  fluid  ac- 
cumulations above  it,  or  by  lateral  deviations  of  the  spine, 
is,    therefore,    not   included   in   the   definition. 

The  condition  was  first  accurately  described  by  Cantani 
in    1866.     Two   forms   are   generally  recognised: 


158  ABDOMINAL    OPERATIONS. 

(a)  Partial    hepatoptosis,    in    which    there    is    a    down- 

ward prolongation  of  a  portion  of  the  liver. 
This  results  in  the  condition  known  as  "  Riedel's 
lobe,"   "floating  lobe,"   or   "linguiform  lobe." 

(b)  Complete  hepatoptosis,   in  which   there  is   a   down- 

fall of  the  whole  organ. 

The  suspensory  apparatus  of  the  liver  seems  at  first  sight 
singularly  unfitted  for  the  burden  that  is  laid  upon  it.  The 
following  are  the  chief  means  by  which  the  gland  is  held  in 
position : 

1.  The  vena  cava.  It  has  been  shewn  by  Faure  that  the 
most  substantial  support  to  the  liver  is  afforded  by  the  vena 
caA^a.  He  likens  the  relation  of  the  vena  cava  and  the  liver 
to  that  which  obtains  in  the  case  of  the  heart  and  the  great 
vessels. 

2.  The  ligaments  proper  to  the  liver. 

3.  The  intra-abdominal  pressure — due,  in  part,  to  the  ten- 
sion of  the  anterior  abdominal  wall,  and,  in  part,  to  the  pres- 
ence beneath  the  liver  of  the  mass  of  the  stomach  and  intes- 
tines. The  influence  of  this  factor,  which  is  considered  of 
the  first  importance  by  Sappey,  Landau,  and  others,  is,  by 
Faure,  not  altogether  denied,  but  asserted  to  be  quite  insig- 
nificant. 

The  dropping  of  the  liver  is  not  a  perfectly  simple  vertical 
movement.  The  posterior  surface  of  the  liver,  owing  to  the 
strong  attachment  of  the  vena  cava,  moves  the  least;  the  an- 
terior border  moves  the  most.  There  is  a  sort  of  nodding 
movement,  or  a  movement  of  rotation  around  a  transverse 
axis  through  the  posterior  part  of  the  organ.  In  addition  it 
must  be  noted  that  the  right,  larger,  lobe  moves  further 
downwards  than  the  left  lobe.  The  anterior  sharp  edge  of 
the  liver  becomes,  therefore,  lower  and  lower,  and  the  upper 
convex  surface  becomes,  at  the  same  time,  more  and  more 
inclined  to  look  forwards. 

Associated  in  manv   cases  with   this   downfall  of  the   liver 


SURGICAL   TREATMENT   OF   VICERAL   PROLAPSE.  1 59 

is  a  marked  deformity,  which  consists  most  often  in  a  flatten- 
ing of  the  gland,  especially  of  the  right  lobe.  The  anterior 
and  inferior  surfaces  are  increased  at  the  expense,  respec- 
tively, of  the  superior  and  the  posterior  surfaces.  In  not  a 
few  cases  a  deep  transverse  furrow  is  seen  to  lie  along  the  an- 
terior surface  of  the  right  lobe;  the  peritoneum  which  lines 
this  groove  is  thick  and  milky  in  its  opacity.  This  shape  of 
the  liver  is  most  often  found  in  association  with  a  Riedel's 
lobe. 

"Riedel's  lobe"  is  a  downward  projection  from  the  right 
lobe  of  the  liver,  immediately  to  the  right  of  the  gall-bladder. 
In  very  rare  instances  the  elongation  may  proceed  from  the 
quadrate  lobe,  immediately  to  the  left  of  the  gall-bladder. 
This  linguiform  process  is  associated  almost  always  with  gall- 
stones, and  is  caused,  so  it  is  said  by  Riedel,  by  the  gradual 
distension  of  the  gall-bladder  dragging  downwards  that  por- 
tion of  the  liver  in  its  immediate  vicinity.  Both  Riedel  and 
Terrier  have  shewn — and  the  observation  has  been  abun- 
dantly confirmed — that  when  the  gall-bladder,  so  affected, 
is  drained  of  its  contents  by  the  performance  of  cholecyst- 
otomy,  the  projection  is  gradually  withdrawn,  and  the  con- 
formation of  the  liver  returns  slowly  to  the  normal. 

The  symptoms  which  are  caused  by  this  downward  slipping 
of  the  liver  need  not  be  detailed  here.  Suffice  it  to  say  that 
the  patients  who  suft'er  therefrom  are,  in  90  per  cent,  of  the 
cases,  women,  in  whom  a  prolapse  of  other  organs — the  kid- 
ney, the  stomach  and  intestines,  and  the  uterus — can  also  be 
recognised.  Hepatoptosis  is  only  a  part  of  a  general  visceral 
prolapse,  a  condition  known  as  enteroptosis,  or  Glenard's  dis- 
ease. It  is  well  known  that  the  sufferers  are,  for  the  most 
part,  neurotic  in  type. 

TREATMENT. 

As  a  rule,  the  most  successful  treatment  consists  in  the 
application  of  a  well-fitting  belt.     The  type  of  inflatable  rub- 


l60  ABDOMINAL   OPERATIONS 

ber  pad  recommended  by  Byron  Robinson  is  probably  the 
most  satisfactory  of  all.  In  the  more  obstinate  cases  sur- 
gical aid  will  be  called  in  for  the  purpose  of  dealing  with  a 
painful  "floating"  lobe  or  of  fixing  a  wandering  liver  which 
cannot  adequate^  be  kept  in  position  by  any  mechanical  sup- 
port. 

Riedel's  lobe  has  been  treated  b}^  excision,  b}^  fixation  to 
the  abdominal  wall,  and  by  cholecystotomy. 

Removal  has  been  performed  by  Langenbuch,  Bastian- 
elli,  and  Lock^'ood;  it  can  be  needed  only  when  the  lobe  is 
the  seat  of  a  pain  that  cannot  otherwise  be  relieved.  Suture 
of  the  lobe  to  the  parietes  was  first  performed  by  Billroth  in 
1884;  later,  by  Tscheming  and  Langenbuch.  The  perform- 
ance of  cholecystotomy  for  this  condition  is,  of  course,  within 
the  experience  of  many  surgeons. 

Total  Hepatopexy. — The  first  operation  for  the  purpose 
of  fixing  the  whole  liver  was  performed  b}^  Gerard-]\Iarchant 
in  1 89 1,  though  it  had  been  suggested  by  Kisbert  in  1884.  He 
sutured  the  thin  anterior  edge  of  the  liver  to  the  costal  mar- 
gin by  silk  sutures.  This  method  has  been  followed  in  the 
majority  of  subsequent  operations.  A  portion  of  the  liver 
substance  has  been  picked  up  by  a  series  of  sutures  of  stout 
silk,  and  each  suture  fixed  to  the  anterior  abdominal  wall  or 
to  the  costal  margin.  For  the  purpose  of  carrying  the  suture 
through  the  liver  the  needle  suggested  by  Kousnetzoff  should 
be  employed.  In  addition  to  the  sutures  so  passed,  undoubted 
help  would  be  gained  by  the  denudation,  by  vigorous  gauze 
friction,  of  all  parts  of  the  liver,  so  that  the  formation  of 
adhesions  might  be  more  certainly  accomplished. 

Legueu  suspends  the  liver  by  a  stout  double  thread  which 
passes  completely  through  it  from  side  to  side. 

Pean,  by  a  procedure  which  he  called  "  cloisonnement  peri- 
toneal horizontal,"  was  able  securely  to  fix  a  mobile  liver. 
He  made  a  transverse  incision  through  the  anterior  abdominal 
wall,  replaced  the  prolapsed  liver,  and  then  erected  a  barrier 


SURGICAL   TREATMENT    OF    VISCERAL    PROLAPSE.  l6l 

below  it  by  suturing  the  peritoneum  of  the  anterior  abdom- 
inal wall  to  that  of  the  posterolateral  wall. 

Francke  adopted  the  following  plan:  A  series  of  sutures 
were  passed  along  all  the  anterior  margin  of  the  liver  except 
the  part  near  to  the  gall-bladder,  uniting  this  edge  to  the  cos- 
tal margin.  Between  the  upper  surface  of  the  liver  and  the 
diaphragm  gauze  was  packed  in  and  left  for  eight  days.  On 
its  removal  firm  adhesions  formed  between  the  two  apposed 
and   granulating   surfaces. 

The  best  plan  to  follow  would  seem  to  me  to  be  this:  To 
make  an  incision  obliquely,  about  one  inch  below  the  mar- 
gin of  the  costal  cartilages;  to  replace  the  liver;  to  fix  the 
anterior  edge  securely  with  several  sutures  to  the  costal  mar- 
gin; to  pack  in  between  the  liver  and  the  diaphragm  and  pos- 
sibly also  beneath  the  right  lobe  of  the  liver  many  strips  of 
gauze,  which  should  be  left  in  place  a  week;  to  keep  the 
patient  absolutely  at  rest  in  bed  (with  the  foot  of  the  bed 
elevated  a  few  inches)  for  at  least  one  month. 

It  must  be  borne  in  mind  that  surgery  is  called  for  only 
in  the  most  extreme  cases,  and  regard  must  always  be  had 
to  the  fact  that  a  neurotic  element  is  a  marked  feature  in  all 
these  patients. 

J.  G.  Clark  ("Surg.,  Gyn.  and  Obst.,  "  1908,  p.  339),  in  a  paper 
on  the  surgical  phases  of  enteroptosis,  groups  the  cases  as  follows: 

1.  Cases  of  congenital  habitus. 

2.  Cases  of  acquired  enteroptosis. 

3.  Cases   of   enteroptosis   following  post-operative   ad- 

hesions, hernia,  or  the  removal  of  large  tumours. 

The  first  type  of  case  is  usually  not  improved  by  operation. 
Cases  of  the  second  type  include  women  who  have  borne  children 
in  rapid  succession,  the  habitually  constipated,  and  the  too 
tightly  laced. 

Clark  mentions  35  cases  with  a  percentage  of  about  half 
this  number  of  symptomatic  cures.  The  types  of  operation  per- 
formed were  Webster's  plastic  operation  on  the  abdominal  wall, 

VOL  I. II 


1 62  ABDOMINAL   OPERATIONS. 

suspension  of  the  sigmoid,  suspension  of  the  transverse  colon  by 
omentoventral  suture,  and  Beyer's  operation.  Amongst  Clark's 
conclusions  are: 

1 .  No  case  should  be  operated  upon  until  medical  and  mechan- 
ical measures  have  been  exhausted. 

2.  Cases  due  to  congenital  habitus  are  unrelieved  by  surgery. 

3.  In  order  for  an  accurate  estimation  of  the  degree  of  ptosis 
:x:-ray  should  be  employed. 

4.  Ptosis  following  childbirth  is  improved  b}^  resection  of  the 
relaxed  ventral  tissue  after  the  method  of  Webster. 

5.  In  marked  cases  of  ptosis  of  the  transverse  colon  with 
stasis  and  symptoms  of  partial  obstruction,  partial  colec- 
tomy is  necessary. 

6.  Redundant  sigmoid  may  necessitate  either  suspension  or 
sigmoidectomy. 

7.  In  all  cases  an  abdominal  support  should  be  worn. 


SECTION    II. 
OPERATIONS  UPON  THE  STOMACH. 


CHAPTER  X. 


OPERATIONS  FOR  PERFORATING  GASTRIC  OR  DUODENAL 

ULCERS. 

The  perforation  of  a  gastric  or  duodenal  ulcer  is  one  of  the 
most  serious  and  most  overwhelming  catastrophes  that  can 
befall  a  human  being.  The  onset  of  the  symptoms  is  sud- 
den, the  course  rapid,  and  unless  surgical  measures  are 
adopted  early,  the  disease  hastens  to  a  fatal  ending  in  almost 
every  instance. 

Perforation  of  the  stomach  is  usually  described  as  being 
of  two  varieties — acute  and  chronic;  but  there  is,  as  I  first 
pointed  out,  an  intermediate  class  of  cases,  not  embraced  by 
either  of  these  terms,  which  is  best  described  as  subacute. 

In  acute  perforation  the  ulcer  gives  way  suddenly  and  com- 
pletely. A  larger  or  smaller  hole  results,  and  through  this 
the  stomach-contents  are  free  to  escape  at  once  into  the  gen- 
eral cavity  of  the  peritoneum. 

In  subacute  perforation  the  ulcer  probably  gives  way  al- 
most as  quickly  as  in  the  acute  form,  but,  owing  to  the  small 
size  of  the  ulcer,  or  to  the  emptiness  of  the  stomach,  or  to  the 
instant  plugging  of  the  opening  by  an  omental  flap  or  tag, 
or  to  the  speedy  formation  of  lymph  which  makes,  as  it  were, 
a  cork  or  lid  for  the  ulcer,  the  escape  of  fluid  from  the  stomach 
is  small  in  quantity  and  the  damage  inflicted  thereby  is  less 
considerable.  The  symptoms  at  their  onset  may  be  as  grave 
as   those   in   acute   perforation,    but   on   opening   the   abdomen 

16.:; 


i64 


ABDOMINAL   OPERATIONS. 


the  ulcer  may  be    found    to   be    sealed    over,  and    no    further 
escape  of  fluid  is  occurring. 

In  the  subacute  form  of  perforation  I  have  found  that 
there  is  always  a  complaint  of  greater  discomfort  for  several 
days  preceding  the  rupture.  Vague  general  or  localised  pains 
have  been  felt  in  the  abdomen,  or  a  sharp  spasm  or  "stitch" 
when  the  patient  turned  quickly  or  attempted  to  laugh.     One 

girl,  a  housemaid,  felt  the 
pain  down  her  left  side,  es- 
pecially when  reaching  up  to 
her  work;  another  said  it 
hurt  her  to  bend,  as  her  side 
felt  stiff.  These  premonitory 
s^^mptoms  are  important,  and 
if  recognised,  the}"  should 
enable  us  to  take  measures 
to  prevent  the  occurrence  of 
perforation.  They  doubtless 
have  their  origin  in  a  local- 
ised peritonitis,  and  the  stiff- 
ness is  due  to  the  unconscious 
protection  of  an  inflamed  area 
by  a  muscular  splint. 

In  chronic  perforation  the 
ulcer  has  slowh'  eaten  its 
way  through  the  stomach- 
coats,  and  a  protective  peri- 
tonitis has  had  time  to  de- 
velop at  the  base.  The  escape  of  stomach-contents  is.  there- 
fore, merely  local;  barriers  of  lympli  confine  the  fluid  to  a 
restricted  area,  and  a  perigastric  abscess  forms.  A  chronic  per- 
foration occurs  more  frequently  on  the  posterior  surface  of 
the  stomach,  and  the  perigastric  abscess  occasioned  thereby  is 
recognised  as  "subphrenic."  The  acute  and  subacute  forms 
of  perforating  ulcer  are  more  common  on  the  anterior  surface. 


Fig.  39. — A  perforating  round  ulcer 
causing  death  in  a  lady  of  twenty-two. 
This  is  the  common  condition.  There 
is  a  chronic  ulcer  with  an  acute  perfora- 
tion (Museum,  of  Royal  College  of  Sur- 
geons of  England,  No.  2396). 


OPERATIONS    FOR   PERFORATING   GASTRIC    ULCERS.  165 

There  can  be  no  doubt  that  recovery  by  medical  treat- 
ment alone  is  possible  both  in  the  acute  and  in  the  subacute 
forms  of  perforation.  I  have  had  two  cases  under  my  care 
in  which  a  diagnosis  of  perforation  had  been  made  by  com- 
petent medical  men.  In  both,  an  operation  was  impossible, 
as  no  skilled  help  was  available  until  the  urgency  of  the  symp- 
toms seemed  to  have  passed  off.  When  I  operated,  many 
months  later,  the  evidence  of  peritonitis  completely  sur- 
rounding the  stomach  was  undeniable.  Though  patients  may 
recover,  their  recovery  cannot  be  urged  as  a  reason  for  the 
delay  or  withholding  of  surgical  help  in  all  cases,  for  the  pos- 
sibility of  spontaneous  recovery,  though  not  denied,  is  yet 
so  remote  as  to  make  it  imperative  to  adopt  operative  treat- 
ment at  the  earliest  possible  moment.  The  risk  of  opera- 
tion is  definite;    the  hazard  of  delay  is  immeasurable. 

It  is  by  degrees  becoming  more  generally  recognised  that 
chronic  ulcers  of  the  stomach  and  of  the  duodenum  are  conditions 
that  can  be  diagnosed  with  an  approximation  to  accuracy  which, 
though  it  leaves  much  to  be  desired  in  the  case  of  the  former,  is 
almost  exact  in  the  case  of  the  latter.  And  increasing  confidence 
is  being  displayed  in  the  view,  which  some  amongst  us  have  long 
expounded,  that  chronic  ulcers  are  in  all  cases  in  need  of  surgical 
treatment.  We  may  accordingly  have  reasonable  expectations 
that  with  earlier  and  more  confident  diagnosis  and  with  a  speedier 
resort  to  operative  measures,  the  final  and  often  long-deferred 
catastrophe  of  perforation  in  a  chronic  ulcer  may  be  wholly 
avoided.  Whenever  a  patient  who  has  complained  at  intervals 
of  indigestion  begins  to  suffer  in  the  present  attack  more  acutely 
than  in  an  earlier  one,  the  signal  of  impending  perforation  is  being 
raised  and  the  clear  warning  should  by  no  means  go  unheeded. 

At  the  moment  when  perforation  occurs  there  is  the  most 
agonising  and  unendurable  pain.  Patients  will  afterwards  say 
that  there  is  no  pain  so  horrible  in  its  torture  as  this.  The  least 
movement  seems  to  add  something  to  its  severity,  so  that  a  pa- 
tient will  perhaps  remain  for  hours  almost  without  stirring.     A 


1 66  ABDOMINAL   OPERATIONS. 

medical  man  upon  whom  I  operated  told  me  that  the  perforation 
had  occurred  while  he  was  crouched  on  his  hands  and  knees  in 
bed  in  a  position  which  seemed  to  relieve  his  pain.  When  the 
rupture  of  the  ulcer  took  place  he  could  not  move  to  reach  the 
bell,  and  had  to  wait  motionless  until  help  came  to  him  in  the 
earlv  morning.  The  tense  rigidity  of  the  whole  body  is  in  strik- 
ing contrast  to  the  ceaseless  unrest  of  a  patient  who  is  suffering 
the  agony  of  hepatic  colic.  In  him  a  constant  change  of  posi- 
tion and  of  pressure  seems  in  some  measure  to  cause  abatement 
of  the  pain,  or,  at  least,  to  be  imposed  upon  the  patient  in  the 
search  for  relief  that  never  comes.  The  abdominal  muscles  are 
found  to  be  in  a  condition  of  inflexible  rigidity,  but  even  here  some 
difference  in  the  various  parts  of  the  abdomen  can  be  felt.  Over 
the  ulcer  the  stiffness  is  of  the  most  obdurate  character;  one 
might  almost  think  that  a  disc  of  metal  replaced  the  supple  muscle. 
This  local  increase  of  a  general  resistance  is  most  definite  and  dis- 
tinct, as  a  rule,  and  it  affords  a  decided  help  not  only  in  the  diag- 
nosis of  the  lesion  but  in  its  location.  The  patient's  expression 
is  of  one  who  is  terror-struck.  The  approach  of  a  hand  to  the 
abdomen  for  the  purposes  of  examination  is  quickly  resented,  and 
the  most  piteous  appeal  for  gentleness  is  made.  The  breathing 
is  short,  jerky,  and  shallow,  and  the  patient  may  indeed  cry  out 
that  he  "cannot  breathe."  This  is  due  in  part  no  doubt  to  a 
spasm  of  the  diaphragm,  and  in  part  also,  I  believe,  to  that  great 
over-distension  of  the  stomach  which  is  so  commonly  seen  when 
the  abdomen  is  opened.  Though  the  patient  looks  generally  ill 
— with  pallid  face,  staring  eyes,  and  sweating  brow — the  pulse 
will  be  found  at  the  first  to  be  hardly  altered  in  frequency  or  in 
volume.  This  is  one  of  the  surprises  which  must  not  fail  to  be 
recognised  and  remembered.  I  have  often  been  told  by  medical 
men  that  at  the  first  view  of  a  case  they  could  hardly  bring  them- 
selves to  believe  in  the  occurrence  of  a  perforation,  since  the  pulse 
was  so  tranquil  and  full ;  and  in  a  case  I  saw  some  years  ago  with 
Dr.  Carlton  Oldfield,  we  deliberately  postponed  for  a  few  hours 
any  question  of  operative  treatment  because  the  pulse,  in  rate  and 


OPERATIONS   FOR   PERFORATING   GASTRIC   ULCERS.  1 67 

volume,  was  normal.  Unhappily,  this  fact  of  the  unaltered  pulse- 
rate  is  even  now  not  generally  recognised;  accordingly  delay, 
which  is  always  serious,  may  occur.  The  pulse  increases  in  fre- 
quency and  depreciates  in  value  very  soon,  but  this  is  due  not  to 
the  perforation  but  to  the  peritoneal  contamination  which  is  the 
inevitable  sequel.  No  one  has  any  difficulty  in  recognising  the 
presence  of  peritonitis,  but  our  aim  must  always  be  to  discover 
at  the  moment  of  its  occurrence  the  lesion  to  which  the  peri- 
toneal infection  is  secondary.  The  symptoms  and  the  signs  of 
the  perforation  of  a  hollow  viscus  are  not  those  of  the  peritonitis, 
which  make  haste  to  develop. 

I  have  seen  a  difficulty  in  diagnosis  arise,  and  I  know  of 
three  cases  in  which  negative  exploration  has  been  per- 
formed, when  the  patient  was  a  woman  at  the  commencement 
of  a  menstrual  period.  From  some  unexplained  and  indeter- 
minate cause  a  sharp  attack  of  abdominal  pain,  followed  by 
vomiting,  distension,  prostration,  and  collapse  had  occurred 
in  all  and  had  caused  a  confusion  in  the  diagnosis.  In  the 
case  under  my  own  observation,  a  history  of  previous  similar, 
though  less  severe,  attacks  at  the  menstrual  epoch,  and  the 
absence  of  any  marked  abdominal  stiffness  or  tenderness, 
though  the  belly  was  obviously  distended,  enabled  me  to 
negative  the  question  of  perforating  ulcer  of  the  stomach. 

The  Operation. — The  operation  should  be  conducted  as 
speedily  as  possible,  and  all  measures  adopted  to  save  the  pa- 
tient from  shock.  The  patient  should  be  operated  upon  in  the 
recumbent  position  so  that  fluid  drains  away  from  the  diaphragm 
which  absorbs  very  rapidly,  to  the  pelvis  from  which  absorption 
is  very  slow. 

The  abdomen  is  opened  in  the  middle  line,  above  the  um- 
bilicus, by  an  incision  of  ample  size.  The  work  which  it  is 
necessary  to  do  cannot  be  efficiently  done  through  a  small 
opening — the  surgeon  must  not  be  cramped.  It  is  quicker 
to  stitch  up  a  large  wound  than  to  operate  through  an  un- 


l68  ABDOMINAL  OPERATIONS. 

duly  small  one.  The  wound  is  made  to  left  or  right,  in  accord- 
ance with  the  discovery  of  that  area  of  greater  local  rigidity  to 
which  reference  has  already  been  made.  It  is  almost  always  pos- 
sible to  make  the  incision  in  the  close  neighbourhood  of  the  ulcer. 
In  some  doubtful  cases  a  small  suprapubic  incision  may  first  be 
made;  the  character  of  the  exudate  will  then  declare  the  nature 
of  the  perforation,  whether  of  the  stomach,  duodenum,  gall- 
bladder, intestine  or  appendix.  The  little  incision  is  used  subse- 
quently for  drainage.  As  soon  as  the  abdomen  is  opened,  gas  or 
a  little  thin,  clear  or  turbid  fluid  will  escape.  Both  gas  and 
fluid  are  inodourous,  and  when  the  fluid  is  examined,  it  is 
found  in  many  cases  to  be  sterile.  The  amount  of  gas  and  of 
fluid  will  depend  upon  the  length  of  time  that  has  elapsed 
since  the  perforation:  if  less  than  six  hours  have  passed,  there 
will  be  little  or  no  gas,  and  the  fluid  will  be  clear  or  almost 
so.  This  fluid  is  poured  out  by  the  peritoneum  as  a  protec- 
tive measure,  and  is  not  only  sterile,  but  is  actively  antibac- 
terial. As  more  and  more  of  the  stomach-contents  escape, 
the  fluid  becomes  more  turbid.  Portions  of  semidigested 
food  may  be  found  in  the  peritoneum,  and  I  once  saw  an 
orange-pip  there. 

The  ulcer  is  rapidly  sought,  and,  as  a  rule,  is  found  at  once. 
It  is  recognised  by  the  escape  of  fluid  from  it,  by  a  thick  de- 
posit of  lymph  around  it,  or  by  the  constant  welling-up  of 
fluid  from  a  particular  part  of  the  stomach.  As  soon  as  the 
ulcer  is  localised,  the  stomach  at  that  part  is  drawn  well  up 
into  the  wound,  and  a  few  swabs  are  packed  around  to  pre- 
vent any  further  soiling  of  the  peritoneum.  The  gap  in  the 
ulcer  is  at  once  closed  by  a  single  stitch  which  passes  through 
all  the  coats  of  the  stomach  on  each  side  of  the  perforation. 
This  closes  the  opening  and  prevents  any  further  escape  of 
stomach-contents.  If  the  stomach  is  full, — and  it  very  often 
is, — it  is  a  good  thing  at  this  stage  to  pass  a  stomach-tube  and 
empty  all  the  contents  away.  The  stomach  may  also  be 
gently  washed  out. 


OPERATIONS   FOR   PERFORATING   GASTRIC    ULCERS.  1 69 

The  perforation  will  often  be  found  surrounded  by  an 
area  of  very  dense  induration,  in  which  a  suture  can  find  little 
securit}^  of  hold.  This  induration  is  almost  entirely  due  to 
oedema  of  the  stomach-wall  around  the  ulcer;  it  is  not,  as  one 
might  suppose  from  the  feel  of  it,  due  to  any  cicatricial  in- 
duration and  contraction  in  the  ulcer  itself.  CEdema  alone 
causes  it,  for  on  postmortem  examination  of  such  cases  the 
induration  is  always  found  to  have  vanished.  There  is  no 
need  to  excise  the  ulcer,  and  this  procedure  is,  in  so  far,  harm- 
ful that  it  wastes  a  few  seconds  and  causes  sometimes  not  a 
little  bleeding.  Excision  of  the  ulcer  is,  however,  performed 
as  a  routine  measure  by  some  surgeons.  The  perforation, 
having  been  closed  by  a  single  stitch,  is  now  effectually 
sealed  by  infolding  the  stomach-wall  by  a  double  layer  of 
suture.  I  always  use  thin  Pagenstecher  thread  and  the 
curved  intestinal  needle  for  this  purpose.  The  first  suture 
begins  about  one  inch  away  from  the  ulcer,  and  continues 
beyond  the  ulcer  about  one  inch.  The  second  stitch  is 
applied  beyond  the  first,  which  it  infolds. 

In  some  instances  the  closure  of  the  gap  may  be  difficult. 
The  opening  may  be  almost  inaccessible,  being  on  the  lesser 
curvature,  close  to  the  cardiac  orifice.  In  these  circumstances 
the  application  of  sutures  in  the  ideal  method  just  described 
may  be  physically  impossible.  The  only  plan,  then,  to 
adopt  is  to  take  one  or  more  interrupted  sutures  through  or 
outside  the  ulcer  and  make  a  closure  of  the  perforation  that 
will,  at  the  least,  be  temporarily  efficient.  To  make  the  sealing- 
off  complete,  an  omental  graft  or  flap  is  then  applied  over  the 
stitches.  The  left  end  of  the  omentum  is  sought  and  turned 
upwards  over  the  stomach,  where  it  can  be  fixed  by  one 
or  more  stitches.  In  one  case  I  have  adopted  this  plan  with 
perfect  success  when  satisfactory  closure  by  suture  alone  was 
impossible. 

The  perforation  being  closed,  attention  must  be  paid  to 
the  toilet  of  the  peritoneum.     The  shorter  the  time  that  has 


170  ABDOMINAL  OPERATIONS. 

elapsed  since  the  giving-wa}^  of  the  ulcer,  the  less  will  there 
need  to  be  done.  If  the  patient  is  operated  upon  within  the 
first  four  or  six  hours,  very  little  cleansing  will  be  necessary. 
A  few  sterile  swabs  passed  to  the  back  of  the  abdomen,  above 
the  lesser  curA^ature,  above  the  liver,  and  into  each  renal 
pouch,  will  ensure  that  all  is  made  clean.  The  abdomen  can 
then  be  closed  without  drainage. 

If,  however,  more  than  twelve  hours  have  elapsed  since 
the  perforation,  and  if  gross  particles  of  food  are  free  in  the  peri- 
toneum greater  care  and  longer  time  must  be  spent  on  ensuring 
that  all  is  clean.  Hot  moist  swabs  are  passed  into  all  the  nooks 
and  crevices  of  the  abdomen.  Especial  care  must  be  taken  to 
see  that  the  parts  immediately  beneath  the  diaphragm  are  thor- 
oughly cleansed — for  the  risk  of  subphrenic  abscess  or  of  a  spread- 
ing of  a  septic  inflammation  through  the  diaphragm,  giving  rise 
to  pleurisy  or  empyema,  is  by  no  means  inconsiderable.  It  is 
absolutely  necessary  that  these  upper  parts  of  the  abdomen 
should  be  left  as  clean  as  it  is  possible  to  make  them.  If  careful, 
methodical,  painstaking  sponging  will  not  suffice,  flushing  with 
hot  sterile  salt  solution  may  be  adopted  in  the  worst  cases.  The 
kidney  pouches,  and  in  most  cases  the  pelvis,  need  also  to  be 
cleansed.  If  the  perforation  has  occurred  more  than  twenty- 
four  hours  before  the  operation,  a  very  thorough  cleansing  will 
be  necessary,  and  in  such  cases  a  second  incision  above  the  pubes 
must  be  made  for  drainage.  Finney  suggests  the  making  of 
multiple  incisions  for  piu-poses  of  flushing  and  drainage,  and  in  ad- 
vanced cases  of  peritonitis  nothing  else  is  so  effective.  The  ques- 
tion of  drainage  can  be  decided  only  by  the  surgeon  himself  in 
each  case.  If  possible,  drainage  should  be  avoided,  but  in  cases 
of  over  twelve  hours'  duration  it  is  probably  necessary  in  at 
least  one-half  of  them.  Drainage,  when  used,  should  be  free, 
and,  as  a  rule,  I  prefer  the  split  rubber  tube  drain  to  any 
other.  When  the  ulcer  has  been  sutured,  a  careful  search  must 
be  made  for  other  ulcers  which  may  have  perforated.  In  two 
cases    of   my  own  two    ulcers    had    simultaneously,   or  almost 


OPERATIONS   FOR    PERFOR.\TING    GASTRIC    ULCERS.  I7I 

simultaneously,  perforated.  In  the  first,  the  two  ulcers  were 
exactly  opposite  each  other — one  on  the  anterior,  one  on  the 
posterior,  surface.  In  the  second,  the  two  ulcers  were  both 
on  the  anterior  surface,  about  i^  inches  apart.  It  has  been 
computed,  from  a  large  number  of  statistics,  that  two  ulcers, 
or  more  than  two,  perforate  in  20  per  cent,  of  the  whole  num- 
ber of  cases.  I  have  already  referred  to  the  necessity,  in 
many  cases,  of  emptying  the  stomach,  and  perhaps  of 
gentle  lavage  also.  This  point  is  one  which  I  have  not  seen 
mentioned  in  the  writings  of  any  surgeon,  but  it  is,  I  am  con- 
vinced, an  important  one. 

In  all  cases  of  duodenal  perforation  and  in  some  of  gastric  per- 
foration the  question  must  arise  as  to  the  need  for  gastro-enter- 
ostomy.  When  an  ulcer  has  perforated,  the  closure  of  the 
resulting  aperture  is  accomplished  by  folding  in  the  wall  of  the 
intestine.  In  a  tube  of  the  calibre  of  the  duodenum,  or  of  the 
juxtapyloric  portion  of  the  stomach  this  results  in  narrowing. 
Even  when  the  suture  is  made  with  the  finest  accuracy,  and  the 
stitches  inserted  along  a  vertical  line,  some  amount  of  stenosis 
is  almost  sure  to  follow  at  once;  and  in  the  subsequent  contrac- 
tion of  healing  this  will  very  probably  become  more  marked.  In 
the  first  case  of  perforated  duodenal  ulcer  upon  which  I  operated 
so  great  a  constriction  of  the  duodenum  was  produced  by  the 
suture  that  I  found  it  necessary  to  perform  gastro-enterostomy 
at  once.  I  have  since  then  had  to  carry  out  a  similar  procedure 
in  other  cases.  It  was  this  experience  which  first  led  me  to  ad- 
vocate the  performance  of  gastro-enterostomy  in  all  cases  where 
a  narrowing  of  the  bowel  had  been  at  once  produced  by  the  ap- 
plication of  the  sutures,  or  where  it  was  likely  to  be  caused  in  the 
subsequent  contraction  which  would  occur  in  the  process  of  heal- 
ing. I  was,  I  believe,  the  first  surgeon  to  advocate  the  perform- 
ance of  gastro-enterostomy  in  suitable  cases  of  perforating  ulcer 
("Lancet,"  1901,  ii,  1656-1663). 

Other  writers  have  since  advocated  the  routine  performance 
of  gastro-enterostomy  in  all  cases  of  perforation  of  the  stomach, 


172  ABDOMINAL   OPERATIONS. 

but  m\'  experience  has  shown  that  this  is  quite  unnecessary. 
Gastro-enterostomy  is  only  to  be  done  in  those  cases  where  an 
obstruction  is  present  or  is  likely  to  develop  from  the  closure  of 
the  ulcer,  or  where  a  second  ulcer  is  seen.  The  advantages  of 
gastro-enterostomy  are;  that  it  permits  a  more  assured  closing 
of  the  ulcer,  for  the  surgeon's  mind  is  not  filled  with  misgivings 
as  to  whether  his  suture  may  be  too  widely  taken ;  that  it  allows 
of  the  early  unrestricted  administration  of  food;  that  it  avoids 
the  recurrence  of  the  ulcer,  or  the  development  of  a  second  ulcer, 
either  of  which  may  perforate. 

A.  B.  Alitchell  ("Trans.  Ulster  Med.  Soc, "  1908,  i,  68)  reports 
a  case  in  which  perforation  occurred  on  July  21,  1907;  the  ulcer 
was  closed  by  sutiu-e  and  the  pelvis  drained ;  a  second  perforation 
occurred  on  March  5,  1908,  and  a  second  operation — closure  of 
the  ulcer  and  gastro-enterostomy — was  performed  with  success.  1 
believe  it  to  be  the  best  practice,  therefore,  to  close  the  ulcer  so 
efficiently  as  to  cut  off  the  pyloric  outlet  from  the  stomach,  and 
to  perform  posterior  gastro-enterostomy  (or  anterior,  if  thought 
better)  at  once. 

As  soon  as  the  operation  is  completed,  the  patient  is  given 
an  enema  consisting  of  10  ounces  of  saline  solution  with  one 
ounce  of  brandy.  This  is  repeated  every  three  or  four  hours, 
or  a  continuous  saline  injection  may  be  given  per  rectum  (Mur- 
phy's method).  No  fluid  is  given  by  the  mouth  for  at  least 
twelve  hours,  and,  if  possible,  not  for  twenty-four  hours,  unless 
gastro-enterostomy  has  been  performed.  In  that  case  any  quan- 
tity of  fluid  may  be  given  from  the  first.  The  mouth  is  fre- 
quently rinsed,  and  the  teeth  are  brushed.  This  will  keep  the 
mouth  moist,  and  will  lessen  the  sense  of  thirst.  If  needed, 
subcutaneous  or  intravenous  injections  of  saline  solution  may  be 
given. 

When  the  patient  has  come  round  from  the  anaesthetic, 
she  is  propped  up  in  bed  with  about  five  pillows  or  with 
the  bed-rest.  This  semi-sitting  posture  is  necessary  as  af- 
fording drainage  of  fluids  away  from  the  diaphragm,   and  as 


OPERATIONS    FOR   PERFORATING   GASTRIC    ULCERS.  1 73 

being  decidedly  more  comfortable  for  the  patient.  For  the 
first  few  days  a  careful  note  must  be  taken  of  the  pulse-rate 
and  of  the  rate  of  the  respirations.  The  most  dreaded  com- 
plication in  cases  of  this  kind  is  the  occurrence  of  some  sep- 
tic inflammation  beneath  the  diaphragm  (subphrenic  abscess) 
or  in  the  chest  (pleurisy  or  empyema).  After  twenty-four 
hours  the  patient  may  be  given  sips  of  water,  milk  and  water, 
a  little  wine  and  water,  or  tea.  It  must  be  remembered  that 
there  is  need  for  careful  dieting  perhaps  for  some  weeks  after 
the  operation. 

PERFORATING  DUODENAL  ULCER. 

In  certain  particulars  the  symptoms  and  the  treatment 
of  perforating  duodenal  ulcer  differ  from  those  of  perforating 
gastric  ulcer. 

A  duodenal  ulcer  may  perforate  at  once  and  acutely  into 
the  peritoneal  cavity,  or  may  slowly  destroy  all  the  coats  of 
the  bowel  and  lead  to  the  formation  of  a  localised  encysted 
abscess.  If  the  former,  the  fluid  escaping  from  the  viscus 
is  free  to  run  at  large  in  the  peritoneal  cavity.  In  many  of 
the  cases,  as  is  seen  from  a  study  of  the  records,  a  well-de- 
fined path  is  taken.  The  fluid  (generally  mucus,  more  or  less 
tinged  with  bile)  escapes  on  to  the  upper  surface  of  the  trans- 
verse mesocolon  to  the  right  of  the  hillock  which  is  formed 
by  the  fitting  in  of  the  transverse  colon  to  the  greater  curva- 
ture of  the  stomach.  It,  therefore,  tends  to  run  to  the  right 
to  the  hepatic  flexure,  and  then  to  descend  along  the  outer 
side  of  the  ascending  colon  to  the  iliac  fossa.  There  collect- 
ing, it  may  cause  symptoms  strongly  suggestive  of  appendi- 
citis. From  the  iliac  fossa  the  fluid  drains  to  the  pelvis,  and, 
filling  that,  overflows  into  the  left  iliac  fossa.  If  an  abscess 
forms,  it  may  be  bounded  by  lymph,  by  the  liver,  or  by  in- 
testines. Meunier  describes  a  local  abscess  in  his  case  as  be- 
ing bounded  by  the  quadrate  lobe  of  the  liver,  the  gall-bladder, 
and  the  transverse  mesocolon.     Lennander  relates  a  case  where 


174  ABDOMINAL   OPERATIONS. 

an  abscess  was  hemmed  in  on  all  sides  by  intestine.  The  per- 
foration of  such  an  abscess  ma}^  lead  to  acute  septic  general- 
ised peritonitis,  as  recorded  by  Planchard.  Perforation  of 
the  upper  portion  of  the  duodenum  may  lead  to  subphrenic 
abscess.  Seven  cases  of  this  kind  are  related  in  JMa^^dl's  mon- 
ograph. An  ulcer  may  destro}^  all  the  coats  of  the  bowel, 
and  its  base  be  formed  by  the  liver  (Ke^d,  Herzfelder,  Collin) 
or  by  the  gall-bladder  (Krauss,  Mo3^nihan).  An  ulcer  may 
destro}''  all  the  coats  of  the  bowel  and  perforate  a  hollow 
viscus,  forming  an  "internal  duodenal  fistula."  Rokitansky 
describes  a  case  .of  gastroduodenal  fistula;  Hoffman  and 
Gross,  cases  of  cholecystoduodenal  fistulae;  and  Duden- 
sing  a  case  where  the  ulcer  had  perforated  the  pancreatic  duct. 
An.  ulcer  may  destroy  all  the  coats  and  lead  to  the  formation 
of  an  abscess,  which  bursts  upon  the  surface  of  the  body,  form- 
ing an  "external  duodenal  fistula,"  as  recorded  by  Lumeau 
and  Bucquoy.  The  duodenal  wall  may  be  ulcerated  through 
by  an  abscess  arising  from  without,  as  in  the  case  of  lumbar 
abscess  bursting  into  the  duodenum  close  to  the  biliary 
papilla  under  the  care  of  DaA'ies-CoUe}^. 

At  the  first  the  symptoms  of  a  perforated  duodenal  ulcer 
are  precisely  similar  to  those  seen  in  cases  of  perforated  gas- 
tric ulcer,  but  after  the  first  hour  has  passed  the  symptoms  and 
signs  of  gastric  and  duodenal  perforation  begin  to  differ  in  their 
development.  When  the  ulcer  is  in  the  stomach,  the  signs 
are  those  of  general  peritoneal  involvement ;  when  the  ulcer  is 
duodenal,  the  course  taken  by  extravasated  fluids  leads  to  a 
more  acute  and  an  earlier  involvement  of  the  peritoneum  on 
the  right  side,  and  in  the  right  iliac  fossa.  The  clinical  picture 
of  appendicitis  is  copied  with  such  accuracy  that  in  49  recorded 
cases  tabulated  by  me  in  the  "Lancet,"  of  December,  1901,  in  18 
the  first  incision  was  made  over  the  appendix  after  a  diag- 
nosis of  acute  appendicitis  had  been  made.  In  the  final  stage, 
the  peritoneal  infection  is  universal. 

When  the  abdomen  is  examined   even  within  the  first  one 


OPERATIONS   FOR   PERFORATING   GASTRIC    ULCERS.  1 75 

or  two  hours,  a  greater  resistance  and  a  more  marked  tender- 
ness may  be  found  upon  the  right  side,  and  the  tenderness 
over  McBurney's  point  may  be  exquisite. 

The  diagnosis  rarely  presents  any  difficulty.  The  symptoms 
are  those  of  an  abdominal  catastrophe,  occurring  in  one  who 
has,  as  a  general  rule,  though  not  invariably  (for  an  acute 
ulcer  may  rupture),  exhibited  those  symptoms  of  duodenal  ulcer 
which  I  have  shewn  to  be  so  characteristic.  The  pain  and  ten- 
derness are  almost  always  greater  on  the  right  side  where  also 
there  is  a  more  obstinate  rigidity  (see  my  book  "Duodenal 
Ulcer,"  second  edition,  1913,  p.  215). 

When  operation  is  performed,  there  may  be  great  difficulty 
in  exposing  the  ulcer.  If  the  ulcer  be  in  the  first  portion  of  the 
duodenum,  it  is  generally  easily  discovered  and  easily  sutured; 
if  the  ulcer  is  "tucked  back,"  it  may  be  impossible  to  suture  it. 
Whenever  practicable,  the  perforation  should  be  closed  com- 
pletely in  the  manner  already  described.  By  so  doing,  the  lumen 
of  the  duodenum  may  be  greatly  narrowed,  so  that  an  alternative 
route  from  the  stomach  must  be  given  by  the  performance  of 
gastro-enterostomy.     This  was  performed  in  several  of  my  cases. 

When  the  ulcer  is  so  deep  that  it  cannot  be  sutured,  or  when 
sutures  however  carefully  introduced  cut  out  at  once,  the  diffi- 
culties of  the  surgeon  are  considerable.  In  such  cases  the  ulcer 
may  be  closed  by  folding  the  two  omenta  over  it.  The  gastro- 
hepatic  omentum  is  drawn  over  the  anterior  surface  of  the  duo- 
denum and  fixed  at  its  lower  border  by  a  few  stitches  or  by  liga- 
tures to  the  gastro-colic  omentum,  at  its  attachment  to  the 
great  curvature  of  the  stomach.  The  extreme  right  portion  of  the 
great  omentum  is  then  turned  upwards  over  the  duodenum  to 
form  a  second  protective  layer  over  the  gastro-hepatic  omentum. 
This  is  the  method  I  adopt,  in  one  form  or  another,  in  all  cases  of 
chronic  duodenal  ulcer.  It  is  known  that  even  after  gastro- 
enterostomy has  been  done,  a  chronic  duodenal  ulcer  may  per- 
forate. In  all  cases  therefore  at  the  time  the  short  circuiting 
operation  is  performed  I  join  the  two  omenta  together  over  the 
duodenum  to  make  a  secure  covering  for  it.     When  an  acute  per- 


176 


ABDOMINAL   OPERATIONS. 


foration  has  occurred  and  the  gap  cannot  be  closed  in  the  ordinary 
manner,  this  method  of  occlusion  by  borrowing  the  omentum 
may  prove  perfectly  satisfactory.  To  make  quite  secure,  how- 
ever, it  would  probably  be  better  in  all  such  difficult  cases  to  close 
the  pylorus  also,  and  to  make  an  alternative  route  from  the 
stomach  by  means  of  gastro-enterostomy.  Lennander,  Mayo 
Robson,  and  others  advised  that  in  such  cases  a  tube  surrounded 
by  gauze  should  be  carried  down  to  the  ulcer,  so  that  a  channel 
might  form  from  the  perforation  to  the  abdominal  wall.     In 


Fig.  40. — Mode  of  closure  of  duodenal  ulcer,  whether  perforating  or  not. 
The  ulcer  is  enfolded  and  the  gastro-hepatic  and  gastro-colic  omenta  are  sutured 
or  ligatured  together  over  the  intestine. 

the  case  of  the  stomach  this  would  mean  that  a  gastric  fistula 
would  result,  which  would  admit  of  closure  after  the  lapse  of  a 
little  time.  In  the  case  of  a  duodenal  ulcer  such  a  procedure 
would  almost  certainly  result  in  the  death  of  a  patient  from 
starvation  in  a  very  few  days.  It  is  remarkable  with  what  rapid- 
ity a  patient  succumbs  who  has  an  external  duodenal  fistula. 
It  is  therefore  absolutely  imperative  in  all  cases  to  close  the  ulcer 
by  suture,  by  grafting,  or  plugging  with,  the  omenta,  or  to  close 
the  pylorus  and  to  perform  gastro-enterostomy. 


CHAPTER  XII. 

OPERATIONS  FOR  CHRONIC  GASTRIC  ULCER,  PYLORIC 
STENOSIS,  ETC.— GASTRO-ENTEROSTOMY. 

Posterior  Gastro-enterostomy. 

The  operation  of  posterior  gastro-enterostomy  is  performed 
in  the  followinsf  manner: 


Fig.  41. — The  "abdominal  incision  in  gastro-enterostomy;    the  anterior  sheath 
of  the  rectus  is  stripped  up  to  the  middle  line. 


An  incision  about  four  inches  in  length  is  made  about  one 
inch  to  the  right  of  the  middle  line  above  the  umbilicus.  The 
anterior  sheath  of  the  rectus  is  opened,  and  the  fibres  of  the 
muscle  are  split,  or,  as  is  far  better,  the  anterior  sheath  is  dis- 


VOL.    I 12 


177 


1/8 


ABDOMINAL   OPERATIONS. 


sected  up  from  the  front  of  the  muscle  as  far  as  the  middle  line ; 
the  whole  bod}^  of  the  rectus  is  then  drawn  to  the  outer  side, 
and  the  posterior  layer  of  the  sheath  is  incised  along  a  line 
exactly  behind  the  incision  in  the  anterior  layer.  The  skin  is 
covered  by  "tetra  cloths"  attached  b^^  the  special  forceps  to  the 
wound  edges  and  ends.     The  abdomen  is  then  opened. 

An  inspection  of  the   whole   of  the   stomach  is   necessary. 
It  may  be  that  an  obvious  thickening  or  puckering  of  an  ulcer 


Fig.  42. — Incision  of  the  posterior  sheath  after  outward  traction  of  the  rectus. 

at  the  pylorus  is  visible  at  once,  but  the  surgeon  must  not  rest 
content  with  this.  A  further  search  must  be  made  on  both 
the  anterior  and  the  posterior  surface  for  other  points  of  thick- 
ening. Not  until  the  whole  stomach  has  been  felt  and  seen 
should  any  operation  be  performed  upon  it.  ]\Iany  mistakes 
have  been  made  from  lack  of  this  precaution. 


POSTERIOR   GASTRO-ENTEROSTOMY, 


179 


The  stomach,  transverse  colon,  and  omentum  are  withdrawn 
from  the  abdomen  and  turned  upwards  to  expose  the  under 
surface  of  the  transverse  mesocolon.  The  origin  of  the  jejunum 
is  then  sought.  Occasionally  the  first  few  inches  of  the  jejunum 
are  attached  to  the  under  surface  of  the  mesocolon  by  adhesions 
possibly  physiological,  possibly  pathological.  The  meso-colic 
band,  a  short  ligament  springing  from  the  under  surface  of  the 


Fig.  43. — The  posterior  surface  of  the  stomach  made  to  project  through  the 
incision  in  the  transverse  mesocolon. 


mesocolon  and  attached  below  to  the  jejunum,  may  extend  on  to 
the  gut  for  3  or  4  inches.  If  it  does  it  should  be  divided  until  the 
jejunum  is  free  up  to  its  origin. 

The  posterior  surface  of  the  stomach  is  exposed  by  making 
an  opening  through  the  transverse  mesocolon  into  the  lesser  sac. 
It  is  sometimes  not  quite  easy  to  divide  the  transverse  meso- 
colon clearly,  and  in  order  to  do  so  I  have  found  the  following 
method  of  great  advantage : 


i8o 


ABDOMINAL   OPERATIONS. 


The  transverse  colon  and  the  stomach  are  held  in  the  sur- 
geon's left  hand,  and  the  mesocolon  is  made  taut.  At  a  blood- 
less spot  in  the  arch  of  the  middle  colic  artery  a  clip  is 
applied   to  the   under   surface  of   the   mesocolon,    and,    having 

secured  a  firm  hold,  it  is  pulled 
away  from  the  posterior  surface 
of  the  stomach.  A  snip  of  the 
scissors  by  the  side  of  the  clip 
opens  the  lesser  sac  at  once.  The 
opening  is  enlarged  by  gentle 
stretching  and  tearing  until  three 
■fingers  can  readily  be  passed 
through  it.  Through  this  open- 
ing the  whole  of  the  posterior  sur- 
face of  the  stomach  is  explored. 
Adhesions  may  be  found  between 
the  stomach  and  the  mesocolon 
or  between  the  stomach  and  the 
pancreas,  and  it  may  be  that  these 
are  so  dense  as  to  preclude  the 
possibility  of  the  performance  of 
the  posterior  operation. 

The  inspection  and  investiga- 
tion of  the  stomach  being  com- 
plete, the  anastomosis  may  be 
made.  It  is  essential  to  see  that 
the  part  needed  for  the  anasto- 
mosis is  brought  through  the  open- 
ing in  the  transverse  mesocolon. 
This  part  consists  of  a  vertical 
fold  in  line  with  the  vertical  por- 
tion of  the  lesser  curvature  and  also  with  the  right  margin  of 
the  oesophagus,  and  it  ends  below  at  the  lowest  point  of  the 
greater  curvature.  A  fold  of  the  posterior  surface  along  this 
line  is  then  seized  by  the  surgeon  and  drawn  well  out  of  the  ab- 


Fig.  44. — Moynihan's  clamp 
for  gastric  and  intestinal  opera- 
tions (made  by  Down  Brothers, 
London) . 


POSTERIOR   GASTRO-ENTEROSTOMY. 


I8l 


domen.  As  the  fold  is  held  in  the  fingers  of  the  left  hand,  it  is 
embraced  by  a  clamp  held  in  the  right  and  applied  vertically, 
the  tip  of  the  blades  pointing  to  the  chin,  the  handle  pointing  to 
the  pubes.     The  amount  of  stomach  held  in  the  clamp  should 

be   3   or   4   inches   in    length.     The 
(ffffS'-ftK  clamp  is  then  turned  transversely, 

the  handle  pointing  to  the  left  side 
of  the  abdomen,  where  it  is  held  by 
[   i    ^i-         .'31  i    t-J.  the  assistant. 


Fig.  45. — Gastro- enteros- 
tomy. The  strip  of  gauze  be- 
tween the  clamps. 


Fig.  46. — The  clamps  completely  sur- 
rounded by  mackintoshes;  all  the  viscera 
within  the  abdomen. 


The  uppermost  portion  of  the  jejunum,  which  has  been  held 
up  to  this  point  by  the  assistant,  is  now  drawn  well  out  of  the  ab- 
domen and  clamped.  The  clamp  is  applied  by  the  assistant, 
while  the  length  of  gut  is  held  by  the  surgeon.  When  the  clamp 
is  in  position,  and  before  it  is  locked,  the  jejunum  at  the  proximal 
end  is  pulled  forwards  so  as  to  make  it  as  taut  as  possible,  while 
the  clamp  held  by  the  assistant  is  depressed.  This  secures  that 
the  clamp  is  applied  as  close  to  the  flexure  as  possible. 


1 82 


ABDOMINAL   OPERATIONS. 


The  two  clamps  are  now  holding  the  portions  of  stomach  and 
intestine  to  be  anastomosed.  The  upper  clamp  holds  a  fold  of  the 
stomach  3I  to  4  inches  in  length ;  the  lower,  a  portion  of  jejunum  of 
the  same  length.     The  portions  of  stomach,  omentum,  and  trans- 


Fig-  47- — G-astro-enterostomy.  The  clamps  in  position;  the  viscera  re- 
turned within  the  abdomen;  the  swabs  placed  in  position.  The  suture  is  now 
commenced. 


verse  colon  outside  the  abdomen  are  now  returned,  so  that  no 
viscera  remain  exposed  except  those  to  be  engaged  in  the 
anastomosis. 

The  two  clamps  are  now  held  apart ;  a  roll  of  moist  hot  gauze 


POSTERIOR   GASTRO-ENTEROSTOMY, 


183 


is  placed  between  them;  over  this  they  are  placed  as  closely 
together  as  possible,  and  around  them  two  mackintosh  cloths 
are  placed,  so  that  nothing  is  now  visible  but  the  two  clamps 
embracing  the  viscera  about  to  be  united.  It  is  an  important 
feature  of  this  operation  that  there  is  no  undue  handling  or 
exposure  of  any  part  of  the  abdominal  contents. 


Fig.  48. — The  first  layer  of  serous 
suture. 


Fig.     49. —  Reinoval    of    the     eUipse     of 
mucous  membrane. 


The  sutures  are  now  introduced;  they  are  all  continuous, 
and  there  is  no  interruption  by  knotting  at  any  part  of  their 
course;  a  needle  of  my  own  pattern  (made  by  Down  Brothers, 
London),  rather  more  than  half  a  circle  in  length  and  with 
a  rounded  body  and  a  slot  eye  for  easy  threading,  is  used,  and 
thin  Pagenstecher  (celluloid)  thread  is  employed  throughout. 
The  first  stitch  picks  up  the  serous  and  muscular  coats  only. 


1 84 


ABDOMINAL   OPERATIONS. 


It  is  commenced  at  the  left  end  of  the  portions  of  stomach 
and  jejunum  enclosed  in  the  clamp,  and  is  continued  until 
the  greater  curvature  of  the  stomach,  at  the  right  end  of  the 
clamp,  is  reached.  The  length  of  the  sutured  line  should  be 
at  least  two  inches ;  its  average  length  is  between  two  and 
three  inches.     The  individual   stitches   are   placed   about   one- 


Fig.   50. — The  beginning  of  the  suture,  which  embraces  all  the  coats;   Allis's 

forceps  in  position. 


eighth  of  an  inch  apart,  and  the  thread  is  drawn  upon  suf- 
ficiently to  ensure  an  easy  approximation  of  the  serous  sur- 
faces. As  each  passage  of  the  needle  through  jejunum  and 
stomach  is  completed,  the  suture  is  pulled  upon  gently,  so  that, 
at  the  same  time,  the  thread  just  introduced  is  tightened  and 
a  little  ridge  or  fold  of  each  viscus  is  raised  up,  making  clear 
the  exact  position  for  the  passage  of  the  needle  next  time. 
When    the    first    row   of   the  stitch  is  complete,  the  needle  is 


POSTERIOR   GASTRO-ENTEROSTOMY. 


185 


laid  aside,  to  be  used  against  a  later  stage  of  the  operation.  On 
either  side  of  this  row  at  a  distance  of  yi  inch  an  incision  is  now- 
made  into  the  stomach  and  jejunum,  the  serous  and  muscular 
layers  of  each  being  carefully  divided  until  the  mucous  membrane 
is  reached.  Before  the  opening  is  made  a  few  pieces  of  moist 
gauze  are  packed  round  the  clamps  to  catch  any  discharge  or 
blood  which  may  escape.     As  the  cut  is  made  the  serous  coat 


Fig.   51. — The  inner  suture,  continued. 

retracts  and  the  mucous  layer  pouts  into  the  incision.  An  ellipse 
of  the  mucous  membrane  is  now  excised  from  both  stomach  and 
jejunum,  the  portion  removed  being  about  134'  to  2^2  inches 
in  length,  and  rather  more  than  half  an  inch  in  breadth  at 
the  centre.  The  gastric  mucosa  shews  a  marked  tendency 
to  retract;  it  is,  therefore,  seized,  together  with  the  serosa,  in  a 
pair  of  miniature  (French)  vulsella  on  each  side.  No  vessels  are 
ligated,  as  a  rule.     The  cut  surface  of  the  bowel  and  stomach  may 


i86 


ABDO:\IIXAL   OPER.\TIOXS. 


occasionally  ooze  slightly ;  this  can  be  checked  at  once  by  tight- 
ening the  clamps  one  notch.  An  Allis's  forceps  is  placed  on  the 
posterior  cut  edges  of  the  incision,  picking  up  the  mucous  and 
serous  coats  of  the  stomach  and  the  serous  and  mucous  coats  of 
the  jejimum.  It  is  placed  at  or  near  the  end  of  the  incision,  near 
the  operator,  and  is  allowed  to  hang  down.  Its  weight  is  suffi- 
cient to  keep  the  cut  edges  now  to  be  sutured  in  apposition  and  to 
make  them  fairlv  taut.     The  inner  suture  is  now  introduced.     It 


Fig.  ^2.  —  The  inner  suture  nearly  completed.     The  mucosa  being  turned 
outwards,  not  inwards. 


embraces  all  the  coats  of  the  stomach  and  jejunum  around 
the  whole  circumference  of  the  opening.  The  needle  is  first 
passed  through  the  wall  of  the  jejunum  from  the  mucous  to 
the  serous  surface  at  the  left  end  of  the  incision,  and  then  from 
the  serous  to  the  mucous  surface  of  the  stomach  at  a  cor- 
responding point;  the  knot,  when  tied,  is  on  the  mucous  sur- 
face. The  needle  is  now  passed,  time  after  time,  from  the 
mucosa  of  the  jejunum  to  the  mucosa  of  the  stomach,  pick- 
ing up  both  serous  coats  in  its  passage.     The  stitch  is  drawn 


POSTERIOR   GASTRO-ENTEROSTOMY. 


187 


tight  enough  to  constrict  any  vessels  in  the  cut  edges,  and  as 
it  is  so  drawn  the  point  for  the  next  introduction  of  the  needle 
is  made  clear.  When  the  stitch  has  been  completed  along 
the  hinder  margin  of  the  incision,  it  is  returned  along  the  an- 
terior margin,  without  interruption  until  the  original  end  of 
the  stitch,  left  long,  is  reached,  when  a  triple  knot  is  tied  and 
the  ends  of  the  suture  are  cut  short. 


Fig.  53. — The  inner  suture  com- 
pleted ;  the  clamps  removed  to  shew 
if  there  are  any  bleeding  points. 


Fig.  54. — The  serous  suture 
resumed. 


The  clamps  are  now  loosened  but  are  left  in  position  in  order 
to  prevent  the  viscera  from  slipping  back  into  the  abdomen. 
If  any  bleeding  vessel  is  seen,  it  is  clipped  and  ligatured.  The 
parts  are  wiped  over  with  hot  moist  swabs,  and  all  instruments 
used  up  to  this  point  are  discarded.  This  is  done  on  the  assump- 
tion that  the  mucous  membranes  of  the  two  viscera  may  contain 
micro-organisms.  As  a  matter  of  fact,  organisms  are  almost  in- 
variably absent  if  the  plan  of  preparation  of  the  patient,  else- 
where described,  is  followed. 


1 88  ABDOMINAL    OPER.\TIONS. 

The  original  serous  suture  is  now  continued.  The  needle 
which  was  laid  aside  is  used  again.  The  only  difficult  part 
of  the  stitch  is  now  encountered,  for  there  are  many  vessels 
along  the  greater  curvature  of  the  stomach  and  near  it  which 
have  to  be  avoided,  and  unless  the  utmost  exactness  is  ob- 
served, a  vessel  may  easily  be  wounded.  If  it  should  be.  a 
deeper  and  wider  stitch  must  be  passed,  and  tied  with  suf- 
ficient firmness  to   check  the  bleeding.     The  suture  is   drawn 


Fig-   55- — Termination  of  the  serous  suture;    the  final  stitch  overlapping  the 

first  one. 


upon  with  moderate  firmness,  with  the  result  that  the  place 
for  the  next  introduction  of  the  needle  is  made  plain.  When 
the  stitch  has  been  carried  around  to  the  point  from  which 
it  originally  started,  the  end  of  the  thread  left  long  is  taken 
in  the  fingers;  with  it  the  stomach  and  jejunum  are  dragged 
gently  upwards,  and  beyond  it  the  needle  is  passed  once  be- 
fore being  tied.  This  is  well  shewn  in  the  figure  (Fig.  55). 
This  affords  an  extra  security  at  a  point  which  might  other- 


POSTERIOR   GASTRO-ENTEROSTOMY. 


189 


wise  be  weak.  The  ends  of  the  stitch  are  knotted  and  cut 
short.  Before  inserting  the  last  two  or  three  stitches,  it  is  well  to 
remove  the  clamps  in  order  to  relieve  the  slight  tension  of  the 
jejunum  especially;  a  greater  security  is,  in  this  way,  given  to  the 
apposition  at  the  termination. 

The  suture  lines  are  now  complete.  The  inner  one  embraces 
all  the  coats  and  is  haemostatic;  the  outer  one  includes  the 
serous  and  muscular  coats,  and  affords  a  wide  approximation 
of   surfaces. 

The  stomach  and  jejunum  are  now  wiped  over  gently  with 


Fig.    56. — The  roll  of  gauze  behind  the  anastomosis  when  pulled  from  side  to 
side  displays  all  parts  of  the  suture  line. 

hot  moist  swabs,  and  the  mackintosh  removed.  A  strip  of 
gauze,  it  will  be  remembered,  was  placed  in  between  the  two 
viscera  before  the  clamps  were  brought  together.  The  end  of 
this  near  the  surgeon  is  now  raised  up  and  turned  towards  the 
left  side  of  the  patient.  The  result  of  this  is  that  the  under,  or 
opposite,  side  of  the  anastomosis  is  disclosed,  and  it  can  then 
be  seen  if  the  suture  line  is  satisfactory.  This  part  also  is 
gently  swabbed.  If  any  part  of  the  suture  line  seems  weak,  a 
separate  stitch  may  be  introduced — this,  however,  is  practically^ 
never  necessary.     The  gauze   strip  is    now  removed,   and   the 


190 


ABDOMINAL   OPERATIONS. 


transverse  colon  and  the  stomach,  which  were  replaced  in  the 
abdomen  before  the  stitching  was  commenced,  are  now  with- 
drawn. In  the  surgeon's  left  hand  the  middle  of  the  transverse 
colon  and  the  lower  part  of  the  stomach  are  grasped,  and  are 
drawn  gentl}"  away  from  the  posterior  wall  of  the  abdomen, 
while,  with  the  right  hand,  the  portions  of  viscera  at  the  anas- 
tomosis are  adjusted  in  the  opening  made  in  the  transA^erse  meso- 


Fig-  5  7- — The  suture  line  complete.  When  the  stomach  and  jejunum  are 
held  up  the  latter  is  seen  to  descend  directly  from  the  flexure  on  to  the  stomach, 
F,  in  the  duodenojejunal  flexure.      (After  W.  J.  Mayo.) 


colon.  A  clip  is  now  placed  upon  the  edges  of  this  opening  on  the 
left  side,  and  a  suture  is  passed  between  this  point  and  the  jeju- 
num just  outside  the  line  of  stitches  at  the  anastomosis.  The 
same  is  done  on  the  right  side,  and  also  at  the  lowest  point  (that 
nearest  the  transverse  colon)  of  the  opening.  These  three  stitches 
hold  the  transverse  mesocolon  in  contact  with  the  jejunum  all 
around  the  line  of  the  sutures.  In  this  manner  additional  security, 
if  such  were  necessary,  would  be  given  to  the  suture  line;  and, 


POSTERIOR   GASTRO-ENTEROSTOMY. 


191 


further,  a  hernial  protrusion  of  the  small  intestine  into  the 
lesser  sac  of  the  peritoneum  is  prevented.  I  prefer  to  stitch 
the  mesocolon  to  the  jejunum  rather  than  to  the  stomach,  as  is 
generally  done.  The  stomach,  colon,  and  omentum  are  now 
replaced  and  the  abdominal  wound  is  closed. 


E-plEL    r^  Vv'RlOrl-r. 


Fig.  58. — The  s.uture  of  the  edges  of  the  opening  in  the  mesocolon  to  the  Hne 

of  anastomosis. 


I  have  used  the  above  method  in  approximately  350  cases 
of  gastro-enterostomy  in  simple  and  malignant  disease.  In 
only  one  case  have  the  mechanics  of  the  operation  been  at 
fault,   and  that  was  in  an  early  case,   when  no  sutures  were 


192 


ABDOMINAL  OPERATIONS. 


passed  through  the  transverse  mesocolon.  The  patient  died 
of  a  hernia  of  all  his  small  intestine  into  the  lesser  sac.  The 
possibilit}^  of  this  is  now  prevented  b}^  the  sutures  between 
the  jejunum  and  mesocolon  which  I  have  described. 


Fig.  59. — The  final  stitches  in  gastro-enterostomy,  uniting  the  margins  of  the 
opening  in  the  transverse  mesocolon  to  the  line  of  anastomosis. 


In  all  cases  of  duodenal  or  pyloric  ulcer  (especially  the  former) 
infolding  of  the  ulcer,  as  is  done  in  cases  of  perforation,  is  de- 
sirable. If  the  ulcer  in  the  duodenum  be  too  large  to  be  infolded 
the  gut  should  be  closed  by  infolding  sutures  upon  the  proxi- 
mal side  of  it.     After  these  sutures  are  tied,  the  gastro-hepatic 


POSTERIOR   GASTRO-ENTEROSTOMY. 


193 


and  gastro-colic  omenta  above  and  below  the  duodenum  are  drawn 
together  by  Hgature  in  such  a  manner  as  to  form  an  additional 
protection  to  the  infolded  ulcer.  It  is  important  to  remember 
that  in  cases  of  duodenal  ulcer  both  perforation  and  haemorrhage 
have  proved  fatal  after  gastro-enterostomy  has  been  performed. 
It  will  be  seen,  from  the  above  description,  that  the  method 
of  suture  is  precisely  the  same  as  that  which  is  adopted  in  most 


Fig.  60. — Gastro-enterostomy.  Shewing  the  position  of  the  anastomosis 
on  the  posterior  wall  of  the  stomach.  Note  the  large  size  of  the  opening,  and 
the  absence  of  a  jejunal  loop. 

cases  of  intestinal  anastomosis.  The  fact  that  the  method 
is  one  which  is  widely  applicable  is,  in  my  judgment,  a  very 
strong  point  in  its  favour. 

The  average  time  for  the  performance  of  the  entire  opera- 
tion is  between  twenty-five  and  thirty  minutes.  I  have  on 
three  occasions  performed  it  in  less  than  twenty  minutes  when 
the  circumstances  were  desperate.  There  is  no  method  of 
gastro-enterostomy   which  is   equally  rapid   and   equally   safe. 


194 


ABDOMINAL   OPERATIONS. 


In  not  one  case  haxe  I  seen  any  fault  in  the  suture  line  when 
the  abdomen  has  had  to  be  reopened  months  or  years  after- 
wards for  other  operations,  such  as  the  removal  of  the  appendix 
or  for  the  performance  of  ovariotomy  or  hysterectom}^ 
The  following  are  the  chief  points  to  be  emphasised: 


Fig.   6i. — Posterior  gastro-enterostomy  with  a  loop;   entero-anastomosis  is  also 

performed. 


AVhen  the  operation  is  completed  and  the  parts  are  be- 
ing replaced,  it  will  be  seen  that  there  is  no  loop  in  the 
jejunum  on  the  proximal  side  of  the  anastomosis. 
The  gut  descends  in  a  straight  line  from  the  flexure 
to  the  posterior  surface  of  the  stomach.  Regurgitant 
vomiting  is   therefore   unknown. 

The  opening  in  the  stomach  is  vertical. 

The   opening  reaches   to   the   very   lowest   part   of  the 


POSTERIOR   GASTRO-ENTEROSTOMY.  1 95 

Stomach,  on  the  greater  curvature.  The  formation 
of  a  pool  of  stagnant  fluid  below  the  level  of  the  anas- 
tomosis is  therefore  impossible. 

The  removal  of  the  mucosa  of  the  stomach  and  jejunum, 
which  results  in  an  opening,  not  a  slit,  being  made  be- 
tween the  two  viscera.  For  thought  of  this  point  I 
am  indebted  to  the  Murphy  button,  which  "stamps 
out,"  as  it  were,  a  portion  of  the  wall  of  both  stomach 
and  jejunum. 

The  large  size  of  the  opening;  the  smaller  opening  made 
is  almost  twice  the  size  of  that  made  by  the  Murphy 
button  or  by  a  bobbin.  The  size  of  the  opening,  more- 
over, can  be  justly  proportioned  to  the  size  of  the 
stomach.  A  large  stomach  necessitates  a  large  anas- 
tomosis.    With  all  mechanical  aids  this  cannot  be  done. 

Absence  of  undue  contraction  in  the  opening  results 
from  the  close  approximation  of  the  cut  edges  of  the 
mucous  membrane  of  the  two  viscera.  There  is,  in- 
evitably, in  cases  of  dilated  stomach,  some  subsequent 
reduction  in  the  size  of  the  anastomosis ;  this  is  in 
direct  proportion  to  the  reduction  which  occurs  in  the 
size  of  the  stomach  itself.  After  a  gastro-enterostomy 
opening  has  been  working  for  six  months  in  a  case  of 
greatly  dilated  stomach,  it  will  always  be  found  that 
some  reduction  in  size  of  the  stomach  has  occurred. 
The  stomach,  in  my  experience,  rarely  returns  to  the 
normal,  but  a  considerable  lessening  in  size  is  often 
appreciable.  At  equal  rate  does  the  opening  become 
reduced. 

It  is  a  common  fault  in  the  performance  of  gastro- 
enterostomy that  the  opening  is  made  too  small — 
often  far  too  small.  The  minimum  length  of  the  open- 
ing should  be  2  inches;  and  in  those  cases  when  the 
stomach  is  greatly  dilated,  it  may  well  be  made  twice 
this  length. 


196  ABDOMINAL   OPERATIONS. 

7.  Suture  of  the  transverse  mesocolon  to  the  suture  line, 
both  stomach  and  jejunum  being  embraced  by  the 
stitch  which  picks  up  the  mesocolon  a  little  distance 
from  the  cut  edge.  The  result  when  the  suture  is  drawn 
tight  is  that  this  cut  rough  edge  is  rolled  inwards 
towards  the  lesser  sac. 


Fig.  62. — Posterior  gastro-enterostomy.      (Mayo's  method.) 


8.  The  inner  suture,  embracing,  as  it  does,  all  the  coats, 

will,  if  properly  applied,  prevent  any  haemorrhage  into 

the  stomach.     The  suture  must  be  firmly    drawn  by 

the  surgeon  himself:     this  important  matter  must  not 

be,  as  it  sometimes  is,  left  to  an  assistant. 

There  have  been  differences  of  opinion  as  to  the  exact  line 

along  which  the  attachment  of  the  jejunum  to  the  stomach  should 

be   made.     Surgeons,    also,    wear    their   rue   with    a    difference. 


ANTERIOR   GASTRO-ENTEROSTOMY.  I97 

There  does  not  in  practice  seem  to  be  much  to  choose  between 
the  results  of  one  method  and  of  the  other:  the  one  essential 
is  that  the  operation  should  be  practised  only  in  those  cases 
where  there  is  a  clear  indication  of  its  necessity.  Hochenegg 
advised  that  in  applying  the  jejunum  to  the  posterior  wall  of  the 
inverted  stomach  the  bowel  should  be  placed  in  such  a  direction 
that  the  line  of  the  ascending  portion  of  the  duodenum  was  con- 
tinued without  any  break;  in  this  way  a  no-loop  antiperistaltic 
anastomosis  is  made.  The  antiperistaltic  method  has  also  been 
advocated  by  W.  J.  Mayo ;  it  has  accordingly  met  with  wide  adop- 
tion, and  has  been  followed  by  equally  satisfactory  results. 


Anterior  Gastro-enterostomy. 

The  foregoing  description  applies  only  to  the  posterior 
operation. 

If,  for  any  reason,  the  anterior  operation  should  have  to 
be  performed,- — for  example,  on  account  of  adhesions  between 
the  posterior  surface  of  the  stomach  and  the  pancreas,  or  of 
the  invasion  of  the  posterior  wall  by  growth,  or  because  the 
mesocolon  is  too  short, — the  same  method  can  be  adopted. 
The  only  difference  is  that  a  point  in  the  jejunum  some  15 
or  18  inches  from  the  flexure  will  be  chosen  for  the  point  of 
anastomosis,  so  as  to  avoid  any  chance  of  compressing  the 
transverse  colon  by  an  unduly  tight  proximal  loop  of  jejunum. 
The  method  of  suture  is  precisely  the  same  as  in  the  posterior 
method,  but  the  stomach  clamp  is  applied  obliquely  in  such  a 
direction  that  the  anastomotic  opening  runs  from  above  down- 
wards and  to  the  left ;  the  degree  of  obliquity,  however,  should 
not  be  too  great.  When  the  jejunum  is  fixed  to  the  stomach  it  is 
desirable  to  make  its  attachment  extend  well  above  the  opening, 
so  that  there  is  no  likelihood  of  kinking  of  the  gut  at  the  upper  end. 
This  may  be  done  by  making  the  outer  row  of  sutures  extend  over 
a  length  of  3  inches,  while  the  opening,  2  inches  in  length,  is  kept 
to  the  lower  end.     The  figure  will  explain  this  point. 


198 


ABDOMINAL   OPER-\TIONS. 


In  the  anterior  operation  an  entero-anastomosis  is  perhaps 
an  advantage.  An  entero-anastomosis  may  also  be  performed 
after  the  posterior  operation  if  a  loop  be  left. 

In  those  cases  of  non-malignant  disease  in  which,  for  mechan- 
ical reasons,  the  posterior  operation  would  be  excessively  difficult 
or  impracticable  I  should  myself  prefer  to  perform  the  anterior  op- 
eration by  Roux's  method.  In  Roux's  operation  the  jejunum  is 
divided  completely  across  about  6  to  9  inches  from  the  flexure ;  the 


Fig.  63. — Anterior  gastro-enterostomy;  shewing  the  outer  suture  embracing 
a  much  longer  portion  of  the  stomach  and  intestine  than  the  inner.  The  greater 
curvature  is  at  the  left  of  the  picture  at  the  tip  of  the  clamp. 


distal  cut  end  is  implanted  into  the  stomach,  and  an  end-to- 
side  anastomosis  performed,  and  the  proximal  end  is  implanted 
into  the  side  of  the  distal,  about  3  inches  from  its  point  of  union 
with  the  stomach.  The  anastomosis  is  made  between  the 
posterior  surface  of  the  stomach  and  the  jejunum,  but  can 
be  made  equally  well  with  the  anterior  surface.  I  have  often 
performed  Roux's  anterior  operation, — the  gastro-enterostomy 
in  Y,  as  it  is  called, — and  the  results  have  been  most  satisfac- 
tory.    Indeed,  the  method  is  in  many  respects  an  ideal  one,— 


ANTERIOR   GASTRO-ENTEROSTOMY. 


199 


it  reproduces  more  nearly  the  normal  conditions,  for  the  bile 
and  pancreatic  juice  after  this  operation  are  introduced  into 
the  bowel  about  3  inches  from  the  new  opening  into  the  stom- 
ach, exactly  as  in  the  normal  duodenum.     Roux's  operation  is 


Fig.  64. — Anterior  gastro-enterostomy;  the  operation  completed.  The 
extension  of  the  outer  suture  well  beyond  the  upper  limit  of  the  opening  is  seen. 
The  jejunum  is  represented  as  transparent  so  as  to  shew  the  position  of  the 
opening. 


said  to  prevent  the  possibility  of  regurgitant  vomiting,  though 
I  know  of  one  case  where  the  vomiting  of  bile  since  the  opera- 
tion has  been  a  constant  feature.  The  disadvantage  of  the 
operation  is  that  it  requires  longer  time  for  its  performance, 


200 


ABDOMINAL  OPERATIONS. 


and  that  in  practice  the  results  are  not  a  shade  better  than, 
if,  indeed,  they  are  as  good  as,  those  which  follow  the  ordinary 
posterior  operation. 

ROUX'S  OPERATION. 

The  stomach-wall  is  clamped  obliquely  so  that  the  tip  of  the 
clamp  holds  the  lowest  point  on  the  greater  curvature,  whilst 


Fig.   65. — Rotix's  operation.     The  jejunal  loop  to  be  divided  is  controlled  by  a 
clamp  which  remains  on  until  both  anastomoses  are  complete. 

in  the  base  of  the  clamp  is  a  portion  of  the  stomach  close  to  the 
lesser  curvature  and  near  the  cardia.  A  long  loop  of  jejunum  is 
then  picked  up,  and  its  base  is  secured  by  a  clamp.  At  least  8  or 
9  inches  should  be  the  length  of  the  loop  whose  base  the  clamp 


ANTERIOR   GASTRO-ENTEROSTOMY.  20I 

holds.  The  loop  embraced  by  the  clamp  is  now  divided  about 
2  inches  from  the  upper  clamped  end,  the  cut  being  extended  into 
the  mesentery.  The  upper  cut  end  of  the  jejunum  is  now  united 
to  the  side  of  the  lower  part,  just  above  the  place  where  it  is 
clamped;  the  union  is  effected  in  the  ordinary  manner  by  suture. 
The  distal  cut  end  is  then  united  to  the  stomach  as  it  is  held  by 
the  other  clamp.  The  anastomoses  are  both  completed  before 
either  clamp  is  removed.  There  is  consequently  no  soiling  of  the 
operation  field  by  gastric  or  intestinal  discharges  or  by  blood. 

The  operation  takes  approximately  forty-five  minutes — 
that  is,  at  least  fifteen  minutes  longer  than  the  usual  operation. 
I  perform  a  modified  Roux'  operation  in  some  cases  where  an  an- 
terior gastro-enterostomy  is  necessary.  The  method  is  as  fol- 
lows: A  loop  of  jejunum  some  i8  inches  long  is  taken,  and  8  or 
9  inches  gripped  in  the  rubber  guarded  clamp.  The  jejunum  is 
then  divided  just  beyond  the  rubber  clamp,  the  distal  portion 
being  held  by  a  Parker  Kerr  clamp.  The  portion  held  in  this 
clamp  is  now  closed  by  a  continuous  Pagenstecher  suture,  the 
stitch  being  taken  at  right  angles  to  the  blade  of  the  clamp,  first 
on  one  side,  then  on  the  other.  On  reaching  the  tip  of  the  clamp 
the  suture  is  held  at  either  end  by  the  surgeon,  while  the  assistant 
in  a  single  movement  opens  the  clamp  and  withdraws  it,  the  sur- 
geon meanwhile  drawing  the  sutures  tight.  This  manipulation 
closes  the  gut,  rolling  its  edges  inwards;  the  stitch  now  returns 
to  its  starting-point,  where  it  is  tied  and  cut.  After  the  closure 
of  the  distal  end  of  the  jejunum  in  this  fashion,  an  anterior  ver- 
tical gastro-enterostomy  is  performed,  and  lastly  the  proximal 
cut  end  of  the  jejunum,  which  has  up  to  this  point  been  held  in 
the  rubber  guarded  clamp,  is  united  by  an  end-to-side  anasto- 
mosis with  the  distal  end  about  4  or  5  inches  below  the  gastric 
anastomosis. 

It  is  curious  to  read  in  many  accounts  of  the  great  difficulties 
encountered  in  the  performance  of  the  operation  of  gastro- 
enterostomy and  of  the  infinite  number  of  modifications  of 
one  sort  or  another  that  have  been  suggested.     In  this  opera- 


202 


ABDOMINAL   OPERATIONS. 


tion,  as  in  all  others,  the  key-note  of  success  is  simplicity.  The 
great  variety  of  suggestions  as  to  "new  methods,"  many  of 
them  uncouth,  shews  beyond  doubt  that  the  principles  un- 
derlying the  operation  have  not  been  adequately  appreciated. 
If  the  posterior  operation  be  performed  in  the  manner  de- 
scribed above,  the  results,  both  immediate  and  remote,  will, 
I  venture  to  sa}^  be  satisfactory.     There  will  be  no  need  of 


Fig.   66. — Rotix's  operation  complete. 

anxiety  as  to  regurgitant  vomiting,  nor  will  there  be  need  or 
possibility  of  entero-anastomosis,  closures  of  proximal  loops, 
division  of  the  pylorus,  and  so  forth. 


COMPLICATIONS  AFTER  THE  OPERATION. 

A  number  of  complications   occurring  after  the  operation 
have  been  recorded.     Among  these  may  be  mentioned: 

1.  Haemorrhage. 

2.  Regurgitant  vomiting. 

3.  Internal  hernia. 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY. 


203 


4.  Separation  of  united  viscera. 

5.  Formation  of  adhesions  at  or  near  the  point  of  anastomosis. 

6.  Peptic  ulcer, 

7.  Chest  compHcations. 

8.  Diarrhoea. 

I.  Haemorrhage. — There  have  been  recorded  at  least  three 
deaths  from  haemorrhage  within  a  few  hours  of  the  completion 
of  the  operation  of  gastro-enterostomy,  and  in  all  the  blood  has 
been  shewn  to  come  from  the  incision  in  the  stomach. 


— ai-. 


Fig.  67. — Position  of  a  patient  in  bed  immediately  after  the  performance  of 
gastro-enterostomy.  As  soon  as  the  patient  comes  round  from  the  anaesthetic 
he  is  propped  up  in  this  way. 


The  bleeding  may  be  due  to  improper  suturing.  Unless 
ligatures  are  applied  to  all  the  bleeding  points  in  the  cut  edges 
of  the  stomach,  the  suture  must  be  applied  in  such  a  manner 
as  to  secure  efficient  control  of  the  vessels.  In  two  of  the  fatal 
cases  interrupted  sutures  were  used;  this  is  bad  practice.  A 
continuous  suture  is  far  more  certain  to  close  the  cut  ends  of 
the  vessel;  between  two  interrupted  sutures  a  vessel  may  bleed 
unchecked.  The  best  suture  is,  therefore,  a  continuous  suture 
which  embraces  all  the  coats. 


204  ABDOMINAL    OPERATIONS. 

After  the  inner  suture  is  completed  and  the  clamps  are  re- 
moved, a  few  moments  should  be  allowed  to  elapse  during  which 
the  stomach  and  intestine  are  lightly  wiped  over  with  a  swab 
wrung  out  of  hot  sterile  salt  solution.  This  pause  in  the  opera- 
tion will  give  time  and  opporttmity  to  any  vessel  inadequately 
controlled  to  bleed.  If  a  bleeding  point  is  seen,  a  separate 
stitch,  taking  all  the  coats  of  both  viscera,  is  passed  and  is  firmly 
tied. 

If  the  inner  suture  is  applied  as  I  have  described,  it  will  be 
found  that  the  mucosa  on  the  side  towards  the  operator  is  not 
turned  in  towards  the  lumen,  but  is  turned  outwards;  it  there- 
fore remains  visible  after  removal  of  the  clamps,  and  a  bleeding 
point  in  it  is  instantly  seen.  If  the  mucosa  is  turned  inwards 
on  this  side  (the  side  where  the  vessels  chiefly  lie),  bleeding  may 
go  on  unperceived  into  the  stomach.  The  prevention  of  haemor- 
rhage is,  therefore,  attained  by — ■ 

(a)  The  use  of  a  continuous  suture. 

(b)  The  embracing  of  all  coats  of  the  suture. 

(c)  The  drawing  of  the  suture  firmly  and  evenly. 

(d)  Inspection   of   the   mucosa   after   removal   of   the 

clamps. 

A  discussion  was  recently  held,  inaugurated  by  Sinclair  White. 
as  to  the  cause  of  haemorrhage  after  gastro-enterostomy.  Sin- 
clair "White  himself  was  inclined  to  hold  the  clamps  used  in  the 
operation  as  a  responsible  factor,  believing  that  after  their  re- 
moval bleeding  might  occur  from  points  Avhich  had  been  missed 
by  the  suture  taken  through  all  the  coats.  The  use  of  clamps  was, 
therefore,  deprecated.  I  cannot  agree  with  this  opinion.  The 
clamps  are  so  useful  during  the  operation,  keeping  the  parts  in 
position,  preventing  the  escape  of  contents,  and  so  forth,  that 
I  should  be  very  loth  to  abandon  them.  If  they  are  used,  it  is, 
of  course,  ver}'-  necessary  to  apply  the  inner  suture  with  great  care, 
placing  each  turn  of  the  thread  close  to  those  already  inserted, 
and  drawing  it  sufficiently  tight  to  ensure  control  of  any  bleeding 
point.  I  have  personally  never  had  trouble  from  haemorrhage 
with  the  method  I  have  described.  R.  C.  Coffey  relates  a  very 
interesting  case  in  which  death  occurred  from  a  wound  in  the 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY. 


205 


stomach  inflicted  by  the  clamps.     The  pressure  of  the  clamps 
need  never  be  so  strong  as  to  inflict  injury  on  the  mucosa. 

Herczel  and  a  few  other  writers  have  recorded  cases  of  death 
due  to  haemorrhage  from  the  ulcer  for  which  gastro-enterostomy 
had  been  performed.  Unless  the  origin  of  the  bleeding  is  de- 
monstrably in  the  ulcer  I  should  feel  disposed  to  think  it  more 
likely  that  the  hsemorrhage  had  occurred  from  the  incision  to 


Fig.  68. — Post-mortem  specimen  of  stomach  mucous  membrane  in  which 
is  shewn  a  stoma  forty-eight  hours  after  a  gastro-enterostomy;  also  a  sHt  in  the 
mucous  membrane  produced  by  clamps.  Crossing  the  slit  is  a  vessel  which  was 
devitalised  by  the  clamp  and  which  gave  way  thirty  hours  after  the  operation , 
producing  a  fatal  hasmorrhage.      [Coffey.] 


the  stomach  wall.  It  is  necessary  in  all  operations  so  to  handle 
the  stomach  as  to  do  as  little  hurt  to  it  as  possible.  If  bleed- 
ing does  occur  from  the  ulcer  it  is  probably  due  to  rough 
handling. 

2.  Regurgitant  Vomiting. — Many  theories  have  been  put 
forward  to  explain  the  occurrence  of  regurgitant  vomiting  after 
gastro-enterostomy.  The  formation  of  a  "spur"  at  the  point 
of  anastomosis  has  undoubtedly  some  influence,  and  has  been 
demonstrated  by  Chlumskij  in  certain  cases  operated  upon  by 
Mikulicz.     It  was  formerly  thought  that  the  sole  cause  was  the 


206  ABDOMINAL  OPERATIONS. 

presence,  in  the  stomach,  of  bile  and  pancreatic  juice.  Riegel, 
Malbranc,  and  Weil  related  cases  where  a  reflux  of  bile  into 
the  stomach  resulted  in  grave  symptoms.  Billroth  remarked 
upon  the  serious  import  of  bile  regurgitation  after  gastro-enter- 
ostomy.  Claude  Bernard  and  others,  founding  their  opinion 
upon  laboratory  experiments,  considered  that  bile  inhibited 
gastric  digestion.  Dastre,  in  dogs  with  gastric  fistulas,  intro- 
duced bile  at  all  stages  of  digestion,  and  concluded  that  the 
alkalinising  effect  of  the  bile  was  swiftly  negatived  by  a  copious 
outflow  of  gastric  juice.  No  ill  effects  were  noticed  either  on 
the  digestive  powers  or  on  the  general  health.  Oddi,  experi- 
menting upon  dogs,  obliterated  the  common  bile-duct  and  united 
the  gall-bladder  to  the  stomach.  All  the  bile  consequently 
flowed  at  once  into  the  stomach,  with  the  result  that  the 
animals  gained  in  weight  and  suffered  not  at  all.  Max  Wick- 
hoff,  Angelberger,  and  Terrier  have  performed  cholecysto- 
gastrostomy  for  obstruction  in  the  common  bile-duct,  and 
Perrin  ("These  de  Lyon,"  1901)  has  suggested  the  routine 
performance  of  cholecystogastrostomy  in  occlusions,  presum- 
ably complete  and  irremediable,  of  the  common  duct.  These 
records  all  shew  that  the  mere  presence  of  aseptic  bile  alone 
is  insufficient  to  induce  vomiting.  Chlumskij  has  suggested 
that  the  regurgitant  vomiting  is  due  to  the  presence  of  pancre- 
atic juice  in  the  stomach.  To  settle  this  point,  Steudel  under- 
took a  series  of  experiments  upon  dogs.  He  divided  the  in- 
testine completely  across  at  the  duodenojejunal  flexure,  closed 
the  duodenal  end,  and  implanted  the  jejunal  into  the  anterior 
wall  of  the  stomach.  The  dogs  lived  and  thrived  for  a  time, 
but  died  from  perforation  of  the  duodenal  loop  by  fragments 
of  bone,  which  had  been  eaten  and  had  passed  from  the  stomach 
through  the  pylorus. 

In  the  "British  Medical  Journal "  of  May,  1901 ,  I  recorded  the 
case  of  a  boy,  aged  six,  upon  whom  I  performed  gastro-enter- 
ostomy  for  complete  rupture  of  the  gut  at  the  duodenojejunal 
flexure.  The  torn  end  of  the  duodenum  was  sutured,  and,  after 
resection  of  a  few  damaged  inches,  the  jejunum  was  joined  to 
the  stomach.  As  a  result,  the  whole  of  the  bile  and  the  pan- 
creatic juice  passed  into  the  stomach.  The  boy  made  a  perfect 
recovery,  and  remained  in  splendid  health  until  the  one  hundred 
and  fourth  day  after  the  operation.     He  then  became  suddenly 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  207 

collapsed  and  died  in  a  few  hours,  death  being  due  to  the  per- 
foration of  the  bowel  by  the  Murphy  button  that  had  been  used 
for  the  anastomosis.  This  case  proves  beyond  dispute  the  in- 
effectiveness of  bile  and  pancreatic  juice  as  sole  agents  in  pro- 
ducing regurgitant  vomiting. 

There  are  four  varieties  of  misdirected  current  after  gastro- 
enterostomy : 

1.  Regurgitation  of  duodenal  contents  through  the  pylorus. 

2.  Escape  of  fluids  from  the  stomach  into  the  afferent  loop. 

3.  Escape  of  fluids  from  the  afferent  loop  into  the  stomach. 

4.  Regurgitation  of  the  contents  of  the  efferent  loop  into 

the  stomach. 

Any  one  of  these  establishes  the  circulus  vitiosus.  Of  these 
four,  the  .third,  the  escape  of  duodenal  contents  from  the  aft'erent 
loop  into  the  stomach,  is  generally  considered  the  most  frequent 
and  the  most  grave. 

Chlumskij  ("Beit.  z.  klin.  Chir.,"  Bd.  xx),  in  discussing  the 
causes  of  regurgitant  vomiting,  suggests  the  following : 

1.  Formation  of  a  spur.     This  is  certainly  the  most  fre- 

quent. When  the  anastomosis  is  effected,  the  two 
limbs  of  the  loop  hang  downwards,  and  a  sharp  kink, 
with  spur-formation,  results  at  the  point  of  junction. 

2.  The  jejunal  displacement  may  cause  a  kink  at  the  duo- 

denojejunal junction,  and  thereby  produce  an  acute 
obstruction  of  the  duodenum. 

3.  The  mucous  membrane  of  the  stomach  may  form  large 

pouting  valves   which  obstruct   the   afferent   opening. 

4.  Closure  of  the  anastomotic  opening,  if  the  mucomucous 

stitch  is  improperly  applied. 

5.  Compression  of  the  efferent  branch  of  the  loop  by  the 

colon  (Doyen). 

6.  Steudel  related  a   case,   operated  upon   by   Czernv,   in 

which  the  opening  in  the  transverse  mesocolon  had 
narrowed  and  constricted  the  efferent  loop. 

7.  In  the  original  operation  of  Wolfler  the  antiperistaltic 

implantation  of  the  jejunum  favoured  regurgitation. 
Of  the  frequency  of  regurgitant  vomiting,  the  following  fig- 
ures give  some  indication:  In  65  cases  operated  upon  by  Czemy, 
I  only  presented  grave  symptoms  of  regurgitation.     Kn  entero- 
anastomosis   was   performed,    and   recovery   speedily   followed. 


208  ABDOMINAL  OPERATIONS. 

In  74  cases  operated  upon  by  Mikulicz,  7  died  of  regurgitant 
vomiting.  In  7  cases  an  entero-anastomosis  was  performed, 
and  of  these,  3  died.  In  215  cases  of  posterior  gastro-enteros- 
tomy  from  the  Heidelberg  clinic,  reported  later  than  those  of 
Steudel  by  Petersen,  there  was  not  a  single  case  of  reflux  vomit- 
ing. In  21  cases  of  anterior  gastro-enterostomy  an  entero- 
anastomosis  was  necessary  in  3. 

A  very  large  number  of  modifications  of  the  operation  of 
gastro-enterostomy  have  been  suggested,  with  the  hope  of  pre- 
venting reflux.  In  Wdlfler's  original  operation,  performed  Sep- 
tember 28,  1881,  the  jejunum  was  united  to  the  stomach  with 
ts  proximal  end  nearest  to  the  pylorus.  Von  Hacker,  in  1885, 
suggested  that  the  jejunal  anastomosis  should  be  made,  not 
on  the  anterior,  but  on  the  posterior,  surface  of  the  stomach, 
which  could  be  reached  by  tearing  through  the  transverse  meso- 
colon. The  point  on  the  jejunum  to  be  utilised  for  the  anas- 
tomosis was  placed  by  von  Hacker  20  to  25  centimetres  from 
the  duodenojejunal  flexure ;  by  Kappeler,  40  to  60  centimetres ; 
by  Chlumskij,  50  centimetres;  by  Kader,  60  to  80  centimetres. 
Petersen  emphasised  the  importance  of  the  anastomosis  being 
as  near  to  the  flexure  as  possible.  In  1883  Courvoisier  per- 
formed a  "  gastro-enterostomie  retrocolique  posterieure  trans- 
mesocolique,"  an  operation  attended  by  no  satisfactor}^  re- 
sults, but  memorable  as  containing  the  germ  of  the  idea  which  von 
Hacker  utiHsed  in  his  method.  In  1892  Jaboulay  suggested, 
and  in  1894  performed,  the  operation  of  gastroduodenostomy ; 
Kiimmell,  in  1895,  independently  suggested  the  same  procedure. 
Mikulicz  and  Villard  strongly  commend  the  method.  Kiim- 
mell divided  the  duodenum  completely,  closed  the  proximal 
end,  and  implanted  the  distal  into  the  stomach.  Jaboula}?-  united 
the  anterior  wall  of  the  duodenum  to  the  anterior  wall  of  the 
stomach,  folding  the  duodenum  .forwards  over  a  hinge  formed 
by  the  pylorus.  Villard  described  his  method  under  the  title 
"  gastro-duodenostomie  sous-pylori  que."  Instead  of  folding  the 
duodenum  over  on  to  the  stomach,  he  anastomosed  the  adja- 
cent surfaces  of  the  stomach  and  duodenum.  Brenner  introduced 
a  retrocolic,  anterior  gastro-enterostomy.  A  loop  of  the  je- 
junum was  passed  through  a  rent  in  the  transverse  mesocolon, 
and  then  pulled  forwards  through  the  omentum  just  below  the 
greater  curvature  of  the  stomach,  and  united  to  the  anterior  wall. 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  209 

In  1887  Rockwitz  drew  attention  to  the  fact  that  in  the 
operation  of  Wolfier  the  current  in  the  stomach  was  opposite 
in  direction  to  that  in  the  duodenum.  To  ensure  an  isoperi- 
stalsis  he  suggested  that  the  proximal  end  of  the  loop  should 
be  fixed  towards  the  cardiac  end  and  the  distal  towards  the  py- 
loric end  of  the  stomach.  In  1898  Roux,  of  Lausanne,  per- 
formed his  method  of  "  gastro-enterostomy  in  Y,"  adapting  to 
this  operation  a  method  that  had  been  practised  in  1892  by 
Maydl  for  jejunostomy.  Roux  divided  the  jejunum  completely 
across,  implanted  the  distal  end  into  the  stomach  and  the  prox- 
imal into  the  side  of  the  distal. 

'  The  operation  of  entero-anastomosis  was  first  suggested  in 
1890  by  Lauenstein,  who  advised  that  the  afferent  loop  should 
be  united  to  a  neighbouring  coil  of  intestine.  In  1892  Braun 
and  Jaboulay  performed  entero-anastomosis  between  the  afferent 
and  efferent  loops.  Doyen  performs  a  gastro-enterostomy  in 
Y  which  is  similar  to  that  adopted  by  Roux,  but  is  anterior  in- 
stead of  posterior,  and  the  approximations  are  made  side  to  side 
and  not  end  to  side.  His  method  is  considered  by  Liicke  to 
be  the  best  of  any  method  yet  suggested.  It  is  practically  a 
gastro-enterostomy,  an  entero-enterostomy,  and  a  resection 
of  the   afferent   loop   combined. 

Several  methods  of  narrowing  the  afferent  loop  with  the  hope 
of  preventing  its  filling  with  stomach-contents  have  been  sug- 
gested. Wolfier  surrounds  it  with  a  circular  stitch;  Chaput 
packs  round  it  with  iodoform  gauze ;  and  von  Hacker  makes 
a  series  of  longitudinal  pleats  in  it.  Tavel  has  shewn  that  in 
his  patient  after  a  few  weeks  no  trace  of  a  fold  could  be  dis- 
covered. 

Several  methods  of  preventing  misdirection  of  the  stomach 
have  been  carried  out ;  the  methods  are  usually  described  as 
"gastro-enterostomy  by  invagination."  Faure  invaginates  a 
cone  of  the  stomach  into  the  distal  segment  of  the  anastomosed 
loop.  Sonnenburg  sutures  the  edges  of  the  stomach  incision, 
leaves  the  threads  long,  passes  them  into  the  jejunum  at  the 
opening  for  the  anastomosis,  and  out  by  a  second  opening 
a  couple  of  inches  distal  to  this.  By  drawing  now  upon 
the  sutures  the  stomach  is  pulled  well  into  the  jejunum.  Rut- 
kowsky,  Witzel,  and  Kader  have  combined  the  operations  of 
gastro-enterostomy  and  jejunostomy,  passing  the  tube  into  the 

VOL.   I — 14 


2IO  ABDOMINAL   OPERATIONS. 

Stomach  and  through  the  gastro-enterostomy  opening  into  the 
distal  segment  of  the  duodenum. 

The  attempted  formation  of  a  vah^e  at  the  new  opening, 
suggested  by  Wolfier  in  1883,  has  been  carried  out  most  effec- 
tively by  Kocher,  who  makes  a  semilunar  incision  in  both  stomach 
and  intestine,  the  convexity  being  upwards. 

Hadra,  in  1891,  was  the  first  to  suggest  that  the  loop  of  the 
bowel  united  to  the  stomach  should  be  attached  to  it  both  above 
and  below  the  opening,  so  that  it  should  be  suspended  from  the 
stomach  by  a  wide  attachment.  In  this  manner  the  forma- 
tion of  a  spur  would  be  effectually  prevented.  Lauenstein, 
n  1896,  suggested  the  suspension  of  the  gut  onty  on  its  proxi- 
mal side. 

The  whole  question  as  to  regurgitant  vomiting  has,  how- 
ever, receded  into  the  background  in  my  experience.  I  never 
see  it  in  any  case  of  mine  now,  nor  have  I  seen  it  in  the  last  few 
hundred  cases.  I  believe  regurgitant  vomiting  to  be  due  usually 
to  a  mechanical  defect  in  the  operation,  a  defect  which  consists 
mainly,  if  not  solely,  in  the  leaving  of  a  loop  of  jejunum  between 
the  flexure  and  the  anastomosis.  This  loop  becomes  "water- 
logged": the  bile  and  pancreatic  juice  distend  it,  being  unable 
to  escape  from  it  easily  into  the  distal  limb.  Regurgitation 
through  the  pylorus  then  occurs ;  or  the  weight  of  the  heavy 
loop  causes  a  kink  at  the  anastomosis  which  closes  the  entrance 
to  the  distal  limb.  In  some  cases  post-operative  adhesions  distal 
to  the  opening  may  be  the  cause  of  that  obstruction  which  is  in- 
variably present  in  cases  of  "regurgitation." 

Bartlett  ("Interstate  Medical  Journal,"  April,  1907)  records 
a  case  of  posterior  gastro-enterostomy  of  the  "no-loop"  variety, 
but  with  an  oblique  iso-peristaltic  anastomosis  which  was  fol- 
lowed by  gastric  shrinkage.  Five  days  after  the  operation  the 
patient  commenced  to  vomit,  this  continuing  until  he  retained 
absolutely  nothing.  At  the  end  of  two  weeks  a  secondary  opera- 
tion was  performed.     Bartlett  writes: 

"The  stomach  which  had  been  greatly  dilated,  was  now 
shrunken,  and  retracted  so  high  up  under  the  ribs,  that  the 
greater  curvature  was  higher  than  the  point  at  which  the  duo- 
denum passed  through  the  mesentery,  hence,  the  one-inch  loop 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  211 

of  jejunum  which  had  pointed  downwards  at  the  completion  of 
the  first  operation  now  pointed  upwards,  the  bowel  being  sharply 
kinked  at  the  suture  line." 

The  afferent  bowel  was  empty,  but  the  duodenum  was  dis- 
tended. Bartlett  attributes  the  condition  to  "too  perfect  gas- 
tric drainage." 

Treatment. — The  treatment  of  regurgitant  vomiting  in  the 
serious  cases  must  be  by  operation ;  an  entero-anastomosis  must 
be  performed.  In  the  slighter  cases  relief  is  often  afforded  in  a 
remarkable  manner  by  lavage  of  the  stomach  every  twenty- 
four  hours  for  a  few  days. 

3.  Internal  Hernia. — Several  cases  of  internal  hernia  fol- 
lowing gastro-enterostomy  are  recorded;  some  of  these  have 
proved  fatal,  some  have  been  remedied  by  subsequent  opera- 
tion. 

One  of  my  own  cases  proved  fatal.  The  following  are  the 
notes : 

The  patient,  a  male  aged  twenty-eight,  was  seen  on  October 
30,  1902.  For  fourteen  months  he  had  suffered  from  indigestion. 
At  the  onset  he  had  an  acute  attack  of  indigestion  lasting  five 
days;  occasional  vomiting  then,  but  no  blood.  He  fainted 
several  times,  and  had  tarry  motions.  During  the  last  three 
months  he  had  become  progressively  worse,  and  lost  over  a 
stone  in  weight ;  had  constant  pain  after  food  and  occasional 
vomiting.  He  could  take  only  fluids,  and  was  "wearing  down" 
fast.  The  stomach  was  moderately  dilated.  Free  HCl  present. 
Old  blood  was  noticed  in  the  stools  in  infirmary  almost  daily. 
At  the  operation  duodenal  and  gastric  ulcers  were  found;  duo- 
denal ulcer  in  first  portion  about  the  size  of  a  threepenny-piece, 
very  hard,  and  slightly  adherent.  A  scar  was  found  on  the 
posterior  surface  of  the  stomach  near  the  pylorus.  The  pa- 
tient died  on  the  tenth  day  of  acute  intestinal  obstruction. 
At  the  postmortem  examination  it  was  found  that  there  had 
been  a  hernia  of  almost  the  whole  of  the  small  intestine  through 
the  rent  made  in  the  transverse  colon,  and  that  the  herniated 
bowel  was  tightly  strangled  at  the  opening. 

Dr.  W.  J.  Mayo  has  recorded  ("Annals  of  Surgery,"  i\ugust, 
1902)  a  case;   the  following  is  an  extract  from  his  description: 


212  ABDOMINAL   OPERATIONS. 

"Abdomen  re-opened.  Gastrojejunal  orifice  nearly  oblit- 
erated and  stretched  to  an  inch  in  length.  Jejunum  twisted 
at  the  site  of  anastomosis  one-half  turn  from  the  left  to  the  right. 
Somewhat  more  than  one-half  of  the  small  intestine  had  passed 
through  the  loop  of  jejunum,  between  the  origin  of  the  jejtinum 
and  the  attachment  to  the  stomach.  The  point  of  entrance 
was  on  the  right  side,  beneath  the  transverse  colon.  The  trac- 
tion weight  of  the  intestines  upon  the  mesenter}'  at  the  inferior 
margin  of  the  loop  had  caused  the  volvulus.  The  mesentery 
at  this  point  was  much  thickened;  the  intestines  were  replaced, 
the  gastrojejunal  fistula  divided,  and  the  opening  into  the 
stomach  closed.  The  opening  into  the  jejunum  was  enclosed 
by  a  purse-string  suture,  and  the  half  of  a  ]\Iurphy  button  was 
introduced  and  a  posterior  gastrojejtinostomy  made.  The 
pyloric  stricture  was  nearly  complete,  the  ulcer  evident^  cica- 
trised. It  is  probable  that  the  part  of  jejimum  immediately  below 
the  anastomosis  passed  through  the  loop  first,  producing  the 
twist  which  was  so  prominent  a  feature  on  opening  the  abdomen. 
As  to  when  this  happened,  it  is  hard  to  tell — probably  not  for 
some  months  after  the  operation.  When  the  process  once  be- 
gan, it  might  be  expected  to  continue  until  such  an  amoimt 
of  intestine  travelled  over  the  loop  as  to  pull  the  mesenter>^ 
taut,  the  symptoms  increasing  as  the  condition  gradually  de- 
veloped. It  is  possible  that  at  the  time  the  juncture  was 
effected  a  sHght  twist  might  have  occurred. 

A  similar  case  is  recorded  by  Dr.  Gray,  of  Aberdeen  ("  Lancet , ' ' 
vol.  ii,  1904,  p.  526): 

The  patient,  an  immarried  woman,  aged  thirtA'-one  years,  was 
seen  by  me  in  consultation  on  the  evening  of  ]\Ia3^  15,  1904.  For 
some  months  she  had  suffered  from  severe  "indigestion,"  in- 
tense epigastric  pain,  radiating  to  the  back,  occurring  almost 
immediately  after  taking  food.  She  had  not  vomited  during 
this  period,  but  had  noticed  that  the  stools  were  xery  dark  on 
several  occasions.  On  ]\Iay  14  she  became  suddenty  collapsed 
and  vomited  a  large  quantity  of  blood.  In  spite  of  medical 
treatment  the  haematemesis  was  repeated  several  times,  although 
not  to  such  a  large  extent.  The  bowels  were  opened  and  the 
stool  contained  a  large  quantity  of  blood.  On  the  evening  of 
the  fifteenth  she  became  again  so  collapsed  that  death  was 
thought  to  be  imminent.     She  had  recovered  somewhat  before 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY,  21 T, 

I  saw  her.  Her  pulse  was  very  feeble  and  irregular.  It  was 
occasionally  as  low  as  120,  but  was  usually  considerably  quicker. 
It  was  estimated  that  she  had  vomited  between  two  and  three 
pints  of  blood.  By  percussion  of  the  shifting  dulness,  limited 
to  the  gastric  area,  it  was  found  that  the  stomach  contained  at 
least  a  pint  of  blood.  Nothing  had  been  given  by  the  mouth 
since  the  onset  of  the  attack.  These  facts,  considered  along 
with  the  presence  of  the  large  quantity  of  blood  in  the  stool, 
made  the  total  blood  lost  amount  to  probably  between  four  and 
five  pints.  It  seemed  that  the  bleeding  had  stopped  and  it  was 
thought  advisable  to  wait  until  the  morning,  as  transference  to 
hospital  would  have  had  a  severe  effect  on  the  patient  in  her 
perilous  condition.  Morphine  was  given  hypodermically  and 
a  careful  watch  was  set.  She  passed  a  fairly  good  night,  but 
early  the  next  morning  she  again  vomited  blood  and  was  re- 
moved to  hospital.  On  arrival  there  she  vomited  a  small  quan- 
tity of  fresh  blood,  so  an  operation  was  carried  out  at  once. 

Chloroform  was  administered,  and  three  pints  of  saline  solu-, 
tion  were  slowly  infused  into  a  vein  at  the  elbow.  The  stomach 
was  exposed  by  a  free  incision.  Blood  was  seen  to  be  present  in 
large  amount  in  the  stomach  and  in  the  whole  length  of  the 
intestines.  Nothing  else  abnormal  about  the  stomach  was  de- 
tected by  inspection  or  palpation.  The  blood  was  squeezed 
through  the  pylorus,  the  stomach  was  opened  posteriorly,  and 
its  interior  was  inspected.  No  ulcer  was  seen.  A  posterior 
retrocolic  gastro-enterostomy  was  performed.  Sutures  alone 
were  used. 

The  patient  vomited  early  on  the  second  day  after  operation. 
The  vomit  contained  a  small  amount  of  "coffee-ground"  ma- 
terial and  was  foul  smelling.  Five  minims  of  liquid  extract  of 
cascara  sagrada  were  given  every  hour,  but  after  three  doses 
she  became  sick,  so  it  was  intermitted  for  twelve  hours  and  then 
begun  again.  An  enema  was  given  on  the  evening  of  the  day 
of  operation  to  clear  the  rectum;  a  tarry  motion  resulted. 
Every  second  day  thereafter  an  enema  was  administered.  On 
the  fourth  day  the  stool  was  free  from  blood. 

About  noon  on  the  sixth  day  she  complained  of  intermittent 
griping  pain  in  the  abdomen.  This  continued  until  the  evening, 
when  it  abated  somewhat.  It  was  thought  probably  to  be  due  to 
flatus,  although  previously  to  this  a  turpentine  enema  brought 


214   •  ABDOMINAL  OPERATIONS. 

away  neither  flatus  nor  feces.  A  small  dose  of  morphine  was 
given.  She  was  quite  comfortable  until  3  o'clock  on  the  morning 
of  the  seventh  day,  when  the  pains  began  again  and  increased 
in  severity  as  the  effect  of  the  morphine  passed  off.  Vomiting 
occurred  on  two  occasions.  At  9  a.  m.  another  turpentine 
enema  was  given,  but  with  no  result.  The  facial  expression  was 
now  somewhat  drawn  and  anxious.  Vomiting  continued  at 
intervals,  but  the  pains  subsided  considerably  after  the  enema. 
The  temperature  and  the  pulse  were  unaffected.  The  latter  had 
become  reduced  in  frequency  from  144  on  the  day  of  operation 
to  100  to  no. 

Intestinal  obstruction  was  diagnosed,  and  immediate  opera- 
tion was  advised.  This  was  declined.  I  prescribed  two  drachms 
of  magnesium  sulphate  by  the  mouth  and  eight  minims  of  liquor 
strychninee  hypodermically.  The  immediate  effect  of  this  was 
to  produce  severe  colicky  pain  and  acquiescence  in  operation, 
which  was  carried  out  at  4  p.  m.  It  was  then  found  that  prac- 
tically the  whole  of  the  small  intestine  had  insinuated  itself  from 
left  to  right  through  the  ring  formed  at  the  first  operation  by  the 
peritoneum  of  the  under  layer  of  the  mesocolon,  that  lining  the 
posterior  abdominal  wall  and  forming  the  upper  layer  of  the 
mesentery,  and  completed  anteriorly  by  the  gastrojejunal  junc- 
tion. It  was  easily  pulled  back  and  the  ring  closed  by  suturing 
the  under  layer  of  the  mesentery  to  prevent  recurrence  of  the 
hernia.  Strangely  enough,  there  was  enormous  distension  of 
the  colon  with  gas.  It  was  found  to  be  quite  patent  down  to  the 
rectum.  It  was  accordingly  punctured  by  a  trocar  and  canula 
and  the  gas  let  out.  A  silk  suture  was  inserted  to  close  the  open- 
ng  made  by  the  trocar,  and  a  piece  of  omentum  was  stitched 
over  that.  The  gastrojejunal  junction  was  found  to  be  per- 
fect. The  patient  vomited  once  during  the  evening  after  opera- 
tion, but  thereafter  recovery  was  uninterrupted,  and  she  left 
the  hospital  on  June  1 3 .  She  was  seen  on  July  5 ,  when  she  looked 
extraordinarily  well.  She  had  suffered  no  pain,  no  indigestion, 
and  no  vomiting  since  her  dismissal.  The  stools  had  been 
normal.     vShe  now  made  no  restrictions  in  her  diet. 

A  case  is  also  recorded  by  Mr.  Barker: 

Under  chloroform  an  incision  was  made  in  the  middle  line 
below  the   umbilicus.     Slipping  the   finger  in   under  the   scar. 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY. 


21. 


not  a  trace  of  adhesion  to  it  could  be  found.  The  wound  was 
then  enlarged  upwards  through  the  old  scar,  which  was  per- 
fectly firm.  Some  free  ascitic  fluid  now  ran  out,  and  dark,  dis- 
tended coils  of  small  intestine  presented  on  both  sides.  The 
transverse  colon  was  sought  for  and  drawn  out  and  was  found 


Fig.  69. — A,  Afferent  jejunum  coming  out  from  under  the  plica  duodeno- 
jejunalis  (b)  ;  c,  termination  of  the  afferent  duodenum  dragged  back  to  the 
hidden  anastomosis,  from  which  (d)  the  efferent  jejunum  is  passing  in  its  turn 
over  the  afferent  portion  (a  to  c) ;  g,  last  part  of  the  ileum  twisted  round  the 
efferent  jejunum  and  terminating  in  (i)  the  end  of  the  ileum  at  the  ileocsecal 
valve;  h,  distended  coils  of  the  jejunum  in  the  general  cavity  of  the  abdomen; 
K,  coils  of  the  ileum  in  the  general  cavity  of  the  abdomen.  It  is  seen  from  this 
diagram  that  the  whole  of  the  small  intestine  with  the  exception  of  the  first  and 
last  seven  or  eight  inches  passed  behind  the  gastro-enterostomy  junction  and 
was  strangulated  over  the  afferent  portion,  where  it  formed  a  large  volvulus 
(Barker) . 


to  be  pale  and  much  contracted.  Search  was  then  made  for 
the  gastro-enterostomy  junction,  but  it  could  not  be  clearly 
made  out.  With  the  finger  I  could  feel  the  plica  duodenoje- 
junalis  at  the  root  of  the  left  side  of  the  mesocolon,  but  the  di- 
rection of  the  first  part  of  the  jejunum  was  not  clear.     On  the 


2l6  ABDOMINAL   OPERATIONS. 

right  side  of  the  middle  of  the  mesocolon  small  intestine  was 
felt  passing  under  some  tightly  constricting  mass,  and  on  draw- 
ing the  coils  aside  the  last  seven  or  eight  inches  of  the  ileum, 
tense  and  contracted  to  the  size  of  the  little  finger,  were  seen 
ending  in  the  normal  csecum  and  twisted  on  its  own  axis.  Fol- 
lowing this  back  it  was  seen  to  pass  behind  the  gastro-enterostomy 
junction  and  to  be  twisted  on  itself  at  the  point  of  constric- 
tion. It  was  now  plain  to  all  present  that  the  whole  of  the  small 
intestine  with  the  exception  of  the  last  seven  inches  or  so  had 
passed  between  the  junction  of  the  stomach  and  jejunum  and 
the  root  of  the  mesocolon  made  two  years  ago,  and  over  the  first 
part  of  the  jejunum  (a)  (afferent),  and  then  down  into  the  gen- 
eral cavity  of  the  peritoneum.  But  not  only  this,  the  whole 
small  intestine  having  thus  passed,  formed  a  huge  volvulus, 
turning  on  its  mesentery  in  a  direction  contrary  to  the  move- 
ments of  a  clock.  When  this  was  recognised,  the  coils  as  a  whole 
were  lifted  up  and  untwisted  one  complete  turn  in  the  direc- 
tion of  the  movements  of  the  hands  of  a  clock.  Only  then  could 
the  last  part  of  the  ileum  (i)  be  withdrawn  from  under  the  con- 
striction, all  previous  efforts  in  this  direction  having  failed.  But 
when  the  volvulus  was  untwisted,  it,  and  all  the  rest  of  the  small 
intestine  above  it,  could  be  easity  and  rapidly  drawn  out.  The 
junction  with  the  stomach  could  now  be  plainly  seen,  and  both 
the  afferent  and  efferent  loops ;  the  coils  were  washed  with 
normal  saline  solution  (warm)  and  the  abdomen  was  closed. 
The  operation  lasted  sixty-five  minutes  and  was  well  borne. 
Convalescence  was  uninterrupted  and  primary  union  was  found 
when  the  stitches  were  removed  on  the  eighth  day. 

A  case  of  internal  strangulation  following  gastro-enteros- 
tomy was  related  before  the  Royal  Academy  of  ^Medicine  in 
Ireland  by  Mr.  Gordon  ("Lancet,"  1905,  a'oI.  ii,  p.  1477).  A 
loop  of  the  bowel  had  passed  from  right  to  left  above  the 
proximal  loop  of  the  jejunum,  there  becoming  strangulated. 
A  second  operation  was  necessary  to  relieve  the  obstruction, 
and  was  successful. 

In  addition,  a  case  of  my  own  has  been  operated  upon  a 
second  time,  and  a  hernia  through  the  opening  in  the  trans- 
verse mesocolon  discovered. 

All  the  forms  of  hernia  can  be  prevented  by  attention  to  two 
points: 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  21 7 

(a)  The  suture  of  the  edges  of  the  opening  in  the  meso- 
colon to  the  stomach,  or,  preferably,  to  the  jejunum. 

(b)  The  avoidance  of  a  loop  of  jejunum  between  the  duo- 

denojejunal flexure  and  the  anastomosis. 

4.  Separation  of  the  united  viscera  has  occurred  only  after 
the  use  of  mechanical  appliances,  and  as  these  are  no  longer 
necessary,  this  complication  is  negligible.  With  the  suture  it 
does   not   occur. 

5.  The  formation  of  adhesions  around  and  about  the  anas- 
tomosis is  very  rarely  seen.  As  a  result  of  them,  a  constric- 
tion of  the  jejunum  may  result,  and  vomiting,  due  to  high 
intestinal  obstruction,  will  occur.  I  once  operated  upon  a 
patient,  upon  whom  gastro-enterostomy  had  been  performed 
by  another  surgeon,  on  account  of  persistent  vomiting.  The 
distal  loop  of  the  jejunum  was  buried  in  dense  adhesions,  which 
reduced  the  calibre  of  the  bowel  to  approximately  a  quarter 
of  its  former  size.  The  proximal  loop  was  greatly  distended. 
A  somewhat  similar  case  is  recorded  by  F.  B.  Lund  ("Boston  Med. 
and  Surg.  Journal,"  May  11,  1905,  p.  549). 

It  is  not  improbable  that  the  tendency  to  the  formation  of 
adhesions  is  due  to  infection  at  the  time  of  operation. 

6.  Jejunal  and  Gastro jejunal  ulcer. — Now  that  we  have  ar- 
rived at  a  stage  in  the  development  of  the  surgery  of  the  simple 
diseases  of  the  stomach  and  duodenum  in  which  we  are  entitled 
to  say  that  many  of  the  technical  difficulties  have  disappeared,  and 
that  almost  all  our  anxiety  as  to  the  immediate  result  of  an  opera- 
tion has  long  been  allayed,  we  are  chiefly  concerned  to  discover  the 
remote  destiny  of  our  patients.  Enquiry  assures  us  that  when 
gastro-enterostomy  is  now  performed  in  suitable  cases,  the  im- 
mediate mortality  is  very  low,  certainly  less  than  2  per  cent.,  and 
the  ultimate  condition  of  the  very  great  majority  of  the  patients 
most  satisfactory.  In  connexion  with  the  operation  there  remains 
only  one  serious  complication  to  be  faced,  that  is,  the  development 
of  a  new  ulcer  in  or  near  the  site  of  the  anastomosis  made  between 
the  stomach  and  the  jejunum.  Of  the  history  of  this  condition  of 
jejunal  or  gastrojejunal  ulcer,  since  its  first  recognition  by  Braun 
in  1899,  it  is  not  necessary  to  speak  here.     A  very  full  account  is 


2l8  ABDOMINAL   OPERATIONS. 

given  in  several  recent  articles,  the  most  notable  of  which  is  by 
Van  Roojen  ("Arch.  f.  klin.  Chir.,"  1910,  xci,  380);  see  also 
Paterson  ("Proc.  Roy.  Soc.  Med.,  "  June,  1909,  and  separate  pub- 
lication),  Wilkie  ("Ed.  Med.  Jour., "  1910).  Van  Roojen  gives  brief 
details  of  89  cases,  and  to  these  three  recorded  by  Wilkie,  two  cases 
upon  which  I  have  operated,  and  cases  privately  related  to  me 
by  Rutherford  Morison,  Norman  Porritt,  and  Basil  Hall,  and 
others,  with  the  three  cases  related  below,  bring  the  total  up  to 
over  100.  It  is  remarkable  that  so  few  cases  are  recorded  in 
American  literature,  seeing  that  the  development  of  the  surgery 
of  the  stomach  has  been  so  active  in  that  country.  It  is  almost 
certain  that  if  they  had  occurred  they  would  have  been  re- 
ported. 

Ulceration  at  the  line  of  suture,  or  in  the  jejunum  very  close 
thereto,  occiirs  almost  exclusively  after  operation  for  simple  dis- 
ease. In  only  one  case  in  the  literature  was  the  gastro-enteros- 
tomy  performed  for  carcinoma ;  this  is  recorded  by  Axel  Key  out 
of  the  practice  of  Lennander  ("Nordisk.  Med.  Arkiv, "  1907, 
xl,  97).  The  patient  was  a  woman,  aged  twenty-five,  who  had  a 
tumour  of  the  pylorus  for  which  resection  followed  by  anterior 
retrocolic  gastro-enterostomy  was  performed.  The  patient  died 
on  the  tenth  day  from  peritonitis.  An  examination  of  the  speci- 
men proved  the  growth  to  be  carcinomatous.  In  the  distal  limb 
of  the  jejunum  were  found  two  small  round  "perforating"  ulcers, 
20  mm.  and  37  mm.  from  the  anastomosis.  In  every  other  case 
recorded  the  disease  was  non-malignant.  The  ulcer  may  be 
single,  or  there  may  be  two,  three  or  four  ulcers.  As  a  rule,  the 
ulcer  lies  close  to,  and  is  exactly  on  the  line  of,  the  anastomosis, 
but  sometimes  it  may  be  an  inch  or  two  away  in  the  bowel,  at 
either  side  of  the  anastomosis.  In  58  cases  Van  Roojen  found  the 
position  to  be — 

In  the  closest  proximity  to,  or  exactly  upon  the  suture  line  in  .  .  46 

In  the  proximal  limb  of  the  jejunum  in 6 

In  the  distal  limb  of  the  jejunum  in 8 

In  or  near  the  point  of  an  entero-anastomosis 2 


COMPLICATIONS    AFTER   GASTRO-ENTEROSTOMY.  219 

The  ulceration  occurs  after  every  form  of  gastro-enterostomy. 
The  following  list  is  given  by  Van  Roojen : 

Anterior  gastro-enterostomy 29 

Anterior  gastro-enterostomy  with  entero-anastomosis 12 

Anterior  gastro-enterostomy  in  "  Y  " 10 

Anterior  gastro-enterostomy  retrocolic i 

52 

Posterior  gastro-enterostomy 20 

Posterior  gastro-enterostomy  with  entero-anastomosis i 

Posterior  gastro-enterostomy  in  "\^  " 3 

Posterior  gastro-enterostomy  antecolic  in  "  Y^  " i 

25 

It  would  appear  from  this  that  twice  as  many  cases  of  jejunal 
ulcer  have  occurred  after  the  anterior  as  have  been  known  after 
the  posterior  operation ;  but  we  have  no  knowledge  of  the  relative 
frequency  of  the  adoption  of  these  two  methods.  Van  Roojen, 
in  order  to  investigate  this  question  with  a  nearer  approach  to 
accuracy,  collected  the  details  of  613  cases  of  gastro-enterostomy 
in  which  10  cases  of  jejunal  ulcer  had  occurred.  There  were  189 
cases  of  anterior  gastro-enterostomy  with  6  cases  of  jejunal  ulcer, 
and  444  examples  of  the  posterior  operation  with  4  cases  of  ulcer. 

The  time  at  which  the  ulcers  appeared  is  given  in  the  following 
table  from  Van  Roojen: 

Within  ten  days  in 3  cases 

Ten  days  to  three  months 5 

Three  months  to  six  months 9 

Six  months  to  twelve  months 10 

One  year  to  one  and  one-half  years 9 

One  and  one-half  years  to  two  years 6 

Two  years  to  three  years 5 

Three  years  to  four  years 8 

Four  years  to  five  years 4 

Five  years  to  ten  years 6 

Ten  years  and  later '. , i  case 

66  cases 

Dr.  Norman  Porritt  has  kindly  furnished  me  with  the  notes 
of  a  case  in  which  two  perforations  occurred,  one  in  a  jejunal  ulcer, 
and  one  in  an  acute  ulcer  on  the  lesser  curvature  of  the  stomach, 
six  days  after  the  operation  of  gastro-enterostomy. 


220  ABDOMINAL   OPERATIONS. 

J.  S.,  tailor,  twenty-nine,  suffering  from  pyloric  stenosis. 
Posterior  gastro-enterostomy  performed  4.30  P.  M.  on  May  7, 
1906.  Did  well  until  6  A.  m.  May  13th,  when  he  had  a  slight 
abdominal  pain,  followed  by  very  severe  attacks  of  pain  at  2  p.  m. 
and  6  P.  M.,  followed  by  abdominal  distension  and  rigidity. 
Operation  May  14th,  5.30  P.  M.  The  abdomen  was  re-opened 
through  the  original  incision.  Dark,  bilious  looking  fluid  found 
free  in  abdomen.  The  anastomosis  lay  far  to  the  left  of  the  mid- 
dle line  sound  and  perfect.  The  jejunum  was  freed  from  the 
mesocolon,  and  in  pulling  it  up  gas  bubbled  from  the  lesser  sac 
and  there  was  seen  a  round,  punched-out  hole  in  the  jejunum 
from  which  bilious  liquid  exuded.  The  hole  was  of  the  diameter 
of  a  small  lead-pencil.  The  perforation  was  closed  with  a  double 
row  of  Lembert's  stitching,  but  on  account  of  the  bad  condition 
of  the  patient  nothing  more  was  done  than  a  hasty  mopping  out 
of  the  lesser  peritoneal  sac  and  the  insertion  of  a  broad  glass 
tube  by  a  stab  incision  above  the  pubes  and  a  gauze  drain  down 
to  the  perforated  ulcer.  As  soon  as  the  glass  tube  reached  the 
pelvis  thick  yellow  liquid  like  semi-digested  food  welled  from  it. 
On  May  15,  iqo6,  at  3  A.  M.,  the  patient  died. 

Post-mortem  Examination. — There  was  no  evidence  of  old 
ulceration  in  stomach  or  jejunum,  but  the  pylorus  w^as  narrowed 
to  a  tunnel  which  would  barely  admit  a  lead-pencil.  It  was  thick- 
ened all  round  and  the  lump  left  at  the  operation  was  now  very 
plainly  recognised.  The  anastomosis  between  the  stomach  and 
the  jejunum  was  sound  and  good,  but  on  the  lesser  curvature  near 
the  pylorus  was  a  round,  punched-out  perforated  ulcer.  The 
ulcer  found  and  stitched  at  the  last  operation  was  examined.  It 
involved  the  w^all  of  the  bowel  farthest  from,  but  opposite  to, 
the  anastomosis,  and  was  a  simple,  punched-out,  circular,  clean- 
cut  hole. 

The  cause  of  the  development  of  a  jejunal  or  a  gastrojejunal 
ulcer  has  not  yet  been  made  clear.  It  is  probably  not  the  same 
in  all  cases.  It  may  be  the  smallness  of  the  opening;  a  bruising 
of  the  edges  of  the  anastomosis,  or  the  development  of  a  haema- 
toma  in  the  wall  of  either  viscus  as  the  result  of  the  wounding  of  a 
vessel  by  a  needle ;  the  persistent  presence  of  excessive  quantities 
of  free  HCl;   or  the  tearing  and  unceasing  irritation  of  an  unab- 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  221 

sorbable  inner  thread  which  has  only  partly  been  released  from 
the  suture  line.  Van  Roojen  found  that  in  only  three  cases  in 
which  an  ulcer  was  found  at  the  line  of  the  anastomosis  was  any 
trace  of  thread  or  silk  to  be  discovered.  In  a  case  of  Battle's 
("Lancet,"  1906,  pp.  274,  1246)  an  inner  suture  inserted  thirteen 
months  before  was  removed  from  the  anastomotic  line,  but  the 
jejunal  ulcer  was  an  inch  away.  Wilkie  ("Edin.  Med.  Jour.," 
19 10,  ii),  in  an  excellent  account  of  some  experimental  work  con- 
ducted to  elucidate  this  question,  shews  that  the  union  of  the 
mucosa  at  the  line  of  anastomosis  occurs  by  granulation  in  about 
seven  days,  and  he  concludes,  on  evidence  that  is  perhaps  a  little 
slender,  that  "the  presence  of  an  unabsorbable  suture  in  the 
granulation  area  tends  to  delay  repair."  Accordingly,  he  con- 
siders it  advisable  to  employ  some  absorbable  material  for  the 
inner  stitch.  The  inner  stitch  is  probably  soon  discharged :  it  is 
the  outer  stitch  which  in  all  probability  perforates  here  and  there 
through  the  mucosa  which  is  found  hanging  at  the  suture  line 
months  after  the  operation. 

It  seems  not  unlikely  that  the  occurrence  of  a  jejunal  ulcer 
may  be  due  to  a  persistence  of  those  causes  which  first  set  at  work 
the  changes  leading  to  the  development  of  the  chronic  ulcer  for 
which  the  gastro-enterostomy  was  performed.  Gastric  and  duo- 
denal ulcers  are  probably  always  secondary,  and  so  far  as  my  own 
clinical  observation  goes,  they  would  appear  to  be  secondary 
to  an  infection  elsewhere,  generally  within  the  abdomen,  but  pos- 
sibly apart  from  it,  in  the  mouth,  on  the  skin,  or  elsewhere.  Of 
all  the  evident  primary  causes,  those  within  the  alimentary  canal 
are  the  commonest ;  of  these  a  diseased  condition  of  the  appendix 
is  by  far  the  most  frequent.  The  appendix  should,  therefore, 
always  be  removed  when  the  operation  of  gastro-enterostomy 
is  being  done,  and  any  other  infective  causes  sought,  and,  if 
found,  dealt  with  radically  if  possible. 

A  search  through  the  recorded  examples  of  this  condition 
shews  that  four  clinical  types  of  ulcer  can  be  recognised : 

I.  The  ulcer  develops  rapidly  and  perforates  shortly  after 


222  ABDOMINAL   OPERATIONS. 

the  operation.  There  are  only  four  cases  which  can  be  included 
in  this  group.  The  circumstances  in  all  are  similar:  Gastro- 
enterostomy was  performed  for  an  ulcer  at  or  beyond  the  pylorus, 
associated  with  hyperacidity,  which  in  two  cases  was  intense; 
the  progress  for  the  first  few  days  was  satisfactory,  then  suddenly 
•there  was  an  acute  onset  of  pain,  followed  by  peritonitis  and 
death.  In  all  cases  an  ulcer  just  beyond  the  anastomosis  was 
found,  and  perforation  has  occurred  into  the  general  cavity. 

II.  The  ulcer  develops  within  a  few  weeks  or  months  of  the 
operation  and  the  symptoms  suggest  a  recurrence  of  the  ulcer 
for  which  the  operation  was  performed,  or  a  stenosis  of  the  new 
opening.  The  cases  in  this  group  are  many.  The  symptoms  are 
very  similar  to  those  which  were  caused  by  the  original  ulcer  in 
the  stomach  or  in  the  duodenum,  for  which  the  gastro-enteros- 
tomy  was  performed;  or  they  can  be  referred  to  a  mechanical 
difficulty  in  the  emptying  of  the  stomach.  These  complaints 
are  attributed  to  a  supposed  "recurrence"  of  the  ulcer.  Sec- 
ondary operations  were  performed  for  disabling  symptoms,  for 
haemorrhage,  or  for  perforation  and  peritonitis.  In  these  last 
instances  acute  perforation  had  occurred  in  a  chronic  ulcer. 

III.  The  ulcer  develops  slowly,  and  insidiously  undergoes  a 
"subacute"  perforation,  with  the  result  that  a  tumour  forms  in, 
or  abutting  upon,  the  epigastrium.  About  two-fifths  of  all  the 
recorded  examples  fall  in  this  category.  There  are  not  usually 
any  symptoms  of  which  the  patient  takes  serious  notice.  As  a 
rule,  only  some  trivial  discomfort  after  meals  or  "indigestion" 
is  noticed;  on  examination  of  the  patient  a  distinct  tumour  is 
felt.  When  the  abdomen  is  opened,  the  jejunum  at  or  near  the 
anastomosis  is  found  adherent,  usually  to  the  parietes.  On  sepa- 
rating the  viscera  a  perforation  into  the  intestine  at  the  site  of  an 
ulcer  a  little  below  the  anastomosis  is  discovered.  The  con- 
dition, it  will  be  seen,  is  precisely  analogous  to  that  of  "subacute 
perforation"  in  the  stomach  (see  "Annals  of  Surger>^ "  1907, 
vol.  xlv,  p.  223). 

IV.  The  ulcer  perforates  into  a  hollow  viscus.     The  ulcer  is 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  223 

of  the  chronic  type,  and  perforation  occurs  after  adhesion  to  a 
hollow  viscus — either  the  stomach  or  the  colon. 

Treatment. — The  treatment  of  a  peptic  jejunal  ulcer  may 
be  beset  with  almost  insuperable  difficulties.  Much  will,  of 
course,  depend  upon  the  conditions  found  at  the  time  of  the  op- 
eration. If  an  acute  perforating  ulcer  be  found,  it  will  probably 
be  enough  in  many  cases  to  close  the  ulcer  by  sutures  and  by 
subsequent  careful  dieting  and  rest  to  avoid  the  recurrence  of 
trouble.  In  the  cases  where  the  ulcer  is  of  the  chronic  type,  and 
especially  in  those  wherein  a  subacute  perforation  has  occurred, 
a  resection  of  the  jejunal  length  engaged  in  the  anastomosis  and 
of  the  adjacent  part  of  the  stomach,  followed  by  the  making  of  a 
new  junction  between  the  stomach  and  the  jejunum  at  a  slightly 
lower  level,  will  be  needed.  If  the  original  anastomosis  has  been 
of  the  posterior  no-loop  variety,  then  the  performance  of  a  re- 
section of  the  anastomosis  is  exceedingly  difficult,  as  I  have  good 
reason  to  know.  In  such  a  case  it  is  better  to  cut  the  jejunum 
across  immediately  above  its  attachment  to  the  stomach,  and 
after  resection  of  the  anastomosis  to  make  the  new  junction  after 
the  "Y"  method  of  Roux.  If  the  ulcer  should  be  at  or  near  the 
anastomosis,  and  a  resection  of  the  kind  just  mentioned  be  im- 
possible, then  I  would  suggest  the  free  opening  of  the  stomach 
by  an  incision  along  the  anterior  surface,  in  order  that  access 
may  be  gained  to  the  ulcer  from  the  gastric  side.  Probably  then 
the  anastomosis  could  be  pushed  from  behind  through  the  wound 
in  the  anterior  wall  of  the  stomach  and  a  resection  of  the  ulcer 
performed.  This  method  I  have  several  times  adopted  for  the 
suture  or  excision  of  ulcers,  apparently  otherwise  inaccessible, 
on  the  posterior  wall  of  the  stomach  adherent  to  the  pancreas, 
following  Pilcher  and  Mayo.  The  operation  may  be  called 
" transgastric  resection  or  suture  of  an  ulcer." 

The  following  three  cases  of  jejunal  ulcer  treated  by  operation 
have  been  under  my  care.  The  original  gastro-enterostomy  in 
Cases  I  and  3  was  performed  by  other  surgeons;  in  Case  2,  by 
myself.     In  none  of  the  cases  was  any  trace  of  the  original  inner 


224 


ABDOMINAL  OPERATIONS. 


suture  discovered.  Case  i  is  remarkable  for  the  fact  that  two 
operations  for  the  excision  of  jejunal  ulcers  were  conducted  within 
a  period  of  seven  months. 


a    --^ 
o    > 


i^ 


-•mtkJS^ 


Case  i. — Old  perforated  duodenal  ulcer.  Posterior  gastro- 
enterostomy. Recurrence  of  duodenal  ulcer.  Jejunal  ulcer. 
Excision  of  anastomosis.     Modified  Roux's  operation. 

M.,   Major  R.  A.   M.   C,   aged  forty-two.     In    1892  whilst 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY. 


225 


abroad  had  an  illness,  associated  with  acute  pain  over  gall-bladder 
region,  pyrexia  and  nocturnal  delirium,  which  was  diagnosed  as 
enteric  fever;  he  was  invalided  to  Malta,  where  he  contracted 
Malta  fever.  After  return  home  attacks  of  acute  pain  in  gall- 
bladder region  kept  recurring  and  were  accompanied  by  vomit- 
ing. During  the  war  in  South  Africa  was  well,  but  on  way  home 
he  woke  suddenly  one  night  with  a  very  sudden  and  acute  attack 
of  pain,  which  did  not  completely  cease  for  three  weeks.  During 
none  of  these  attacks  did  he  have  jaundice,   hasmatemesis,   or 


Fig.  71. — Case  i. 
The  parts  removed  at  the  second  operation.      An  ulcer  which  was  on  the  verge 

of  perforation  is  seen. 

melaena.  During  the  next  two  years  the  attacks  of  pain  kept  re- 
curring; pain  nearly  always  occurred  two  or  three  hours  after 
food.  A  diagnosis  of  gall-stones  was  made,  and  operation  ar- 
ranged for  in  April,  1902.  Five  days  before  date  fixed  for  opera- 
tion a  sudden  attack  of  most  excruciating  pain  in  the  upper  ab- 
domen, which  persisted  until  the  operation  was  performed.  The 
condition  then  found  was  a  perforated  duodenal  ulcer  evidently 
on  the  upper  and  posterior  wall,  with  considerable  localised  peri- 
tonitis.     The    perforation    was    closed    and    the    gall-bladder 

VOL.   I — 15 


226  ABDOMINAL   OPERATIONS. 

drained,  although  so  far  as  can  be  learned  no  gall-stones  were 
found. 

During  the  six  months  following  operation  he  had  no  trouble, 
but  then  he  began  to  have  a  return  of  the  pain,  although  it  was 
not  quite  so  definite  in  its  onset  after  food  as  before  his  first 
operation.     There  was  no  A^omiting. 

In  Ma}^,  1903,  posterior  gastro-enterostomy  was  performed 
by  the  same  surgeon  in  London.  For  six  to  eight  months  he 
was  subject  to  attacks  of  biliary  vomiting;  these  then  ceased, 
but  pain  began  to  recur  and  lasted  for  three  to  four  weeks ;  usu- 
ally it  was  reheved  by  a  milk  diet. 

In  1904  pain  was  ven,^  severe,  and  a  diagnosis  of  jejunal 
ulcer  was  made;  he  was  put  on  fluid  diet  for  months,  with  re- 
lief. During  1906  and  1907  was  much  better  and  had  only  one 
or  two  attacks,  which  occurred  after  playing  golf. 

In  July,  1908,  passed  a  very  tarry  motion  but  had  no  pain. 
In  September  a  much  worse  attack,  with  acute  pain  situated 
midwaA^  between  umbilicus  and  left  costal  margin.  He  was 
in  a  nursing  home  under  treatment  with  antilytic  serum,  which 
appeared  to  relieve  the  pain  temporarily.  On  December  8th  he 
woke  at  4  A.  ]M.  with  a  feeling  of  oppression  in  stomach,  followed 
by  vomiting  of  between  three  and  four  pints  of  blood;  melsena 
for  several  days  after.  Since  that  time  has  had  saurin  treatment, 
etc.,  but  the  pain  has  kept  recurring,  most  frequently  at  2  A.  m. 

When  seen  by  me  in  March,  1909,  I  made  the  following  diag- 
nosis: Duodenal  ulcer,  possibly  jejunal  ulcer.  Patent  pylorus, 
partial  closure  of  anastomotic  opening. 

Operation  was  performed  on  March  24,  1909.  Incision  just 
to  right  of  middle  line,  close  to  old  incision.  The  gall-bladder 
margin  of  liver  and  stomach  were  found  to  be  involved  in  a  mass 
of  tough  adhesions  which  were  separated  with  much  difficulty; 
the  omentum  and  transverse  colon  were  turned  up  over  the  an- 
terior aspect  of  the  stomach  and  were  adherent  to  the  anterior 
abdominal  wall. 

The  parts  were  defined,  and  it  was  found  that  a  large  indu- 
rated scar  was  present  in  the  anterior  wall  of  the  first  part  of  the 
duodenum. 

The  gastro-enterostomy  was  next  examined,  and  it  was  found 
that  the  opening  was  patent,  but  the  two  limbs  of  the  jejunum 
were    almost    parallel    up    to    the    anastomosis;     a    considerable 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  227 

"loop"  was  present.  After  the  firm  surrounding  adhesions  had 
been  separated,  the  anastomosis  was  carefully  palpated,  an  in- 
durated "knot"  was  felt  on  the  mesenteric  aspect  of  the  gut  just 
opposite  the  gastro-enterostomy  opening.  This  was  thought 
to  indicate  a  jejunal  ulcer,  so  it  was  decided  to  excise  the  anas- 
tomosis. The  two  limbs  were  clamped  and  divided,  and  the 
stomach  incised  with  scissors  just  around  the  anastomotic  open- 
ing. 

The  end  of  the  efferent  limb  was  next  closed  by  suture,  and 
a  lateral  anastomosis  performed  between  it  and  the  opening 
already  existing  in  the  stomach.  The  proximal  limb  was  next 
implanted  into  the  distal  by  an  end- to-side  anastomosis.  The 
raw  surface  left  by  the  ligation  of  the  mesentery  was  covered  in 
as  completely  as  possible.  Duodenal  ulcer  and  pylorus  infolded 
by  several  sutures.  Abdomen  closed.  The  operation  was  ex- 
tremely difficult  throughout  and  took  two  and  one-half  hours. 

October,  1909.  Since  operation  he  has  not  been  any  better 
but  his  pain  has  been  constant  both  night  and  day,  though  vary- 
ing much  in  intensity.  For  example,  he  had  always  more  when 
he  took  any  exercise.  His  pain  was  localised  to  a  small  area, 
just  to  the  left  of  the  umbilicus,  and  here  he  thought  he  could 
feel  a  lump,  but  no  one  else  has  made  this  out.  He  finds  food 
of  any  sort  sets  the  pain  going  in  a  few  minutes.  The  pain  is  a 
constant  hot  sensation  which  never  actually  leaves  him,  and 
which  is  particularly  bad  at  night.  He  has  been  having  small 
doses  of  morphine  at  nights  since  the  last  operation  in  June. 
He  has  tried  olive  oil  treatment  without  benefit ;  the  only  things 
that  relieve  him  are  strong  alkalis  and  morphine.  He  has  lost 
a  considerable  amount  of  weight  of  late. 

Further  operation,  October  7,  1909.  Incision  through  right 
rectus  in  one  of  the  old  scars ;  a  very  firm  mass  of  adhesions  was 
met  with  and  much  time  spent  in  separating  them;  at  length 
the  site  of  the  last  operation  was  exposed,  the  "Y"-shaped  junc- 
tion of  jejunum  being  found  in  good  order.  The  transverse 
colon  was  now  turned  up  and  the  posterior  gastro-enterostomy 
exposed,  the  lesser  sac  having  been  opened  and  numerous  ad- 
hesions having  been  separated.  On  palpation  a  hard  mass  could 
be  felt  in  the  posterior  part  of  the  line  of  suture,  with  a  crater  in 
its  centre,  and  the  whole  mass  being  the  size  of  a  shilling.  It  was 
decided  to  detach  this  gastro-enterostomy  and  remove  the  loop 


228  ABDOMINAL   OPERATIONS, 

of  small  intestine  down  to  the  "Y  "-shaped  junction,  and  to  do  a 
new  anterior  gastro-enterostomy.  The  stomach  was  closed  by 
two  rows  of  interrupted  Pagenstecher  stitches. 

The  "Y  "-shaped  junction  was  detached  and  the  lower  seg- 
ment closed  so  as  to  reproduce  the  normal  line  of  bowel.  The 
stomach  and  transverse  colon  were  turned  up  and  the  jejunum 
followed  up  to  its  union  with  the  stomach,  and  with  some  diffi- 
culty the  line  of  union  was  defined.  In  separating  the  numerous 
adhesions  the  jejunal  ulcer  which  had  been  felt  on  the  posterior 
surface  of  the  anastomosis  ruptured  at  the  bottom  of  its  crater, 
where  it  was  extreme^  thin.  The  anastomosis  was  detached 
with  a  collar  of  stomach  wall,  and  several  blackened  Pagenstecher 
sutures  of  the  last  operation  were  found,  mostly  in  the  lumen  of 
the  bowel,  attached  by  one  end  to  the  wall.  The  hole  in  the 
lesser  sac  was  closed  by  the  portion  of  mesentery  belonging  to  that 
portion  of  jejunum  leading  from  the  old  gastro-enterostomy  to 
the  "Y "-shaped  junction;  this  portion  of  the  gut  was  now  re- 
moved. A  new  anterior  gastro-enterostomy  was  now  performed 
in  the  usual  wa}^  with  as  short  a  loop  as  possible. 

Case  2. — Duodenal  ulcer.  Ulcer  sutured.  Posterior  gas- 
tro-enterostom}^  Appendicectomy.  Jejunal  ulcer.  Excision. 
Mrs.  S.  Sent  by  Dr.  Edgecombe,  Harrogate.  Admitted  to 
Nursing  Home  November  28,  1910.  All  her  life  she  has  had 
"indigestion,  "  worse  of  late  years.  She  says  it  is  an  aching  pain 
coming  on,  as  a  rule,  two  hours  after  food;  it  comes  on  in  attacks 
lasting  some  days  or  weeks;  after  a  few  days  in  each  attack  the 
pain  comes  irrespective  of  the  taking  of  food,  but  then  food  re- 
lieves it.  She  practically  never  vomits.  The  attacks  have  be- 
come worse  of  late,  but  she  had  an  attack  in  November,  1909, 
and  not  another  until  a  few  weeks  ago,  though  in  between  there 
is  some  trouble  of  a  much  slighter  type.  The  pain  is  always 
worse  in  winter,  and  is  situated  invariably  above  and  to  the  left 
of  the  umbilicus,  the  area  here  being  very  tender.  She  has  not 
had  hasmatemesis  or  melaena  or  jaundice,  and  had  not  lost  weight 
except  in  the  attacks,  gaining  it  at  once  in  the  quiescent  intervals. 

November  30,  1910.  Incision  through  right  rectus.  Very 
well-marked  duodenal  ulcer  one-half  inch  beyond  pylorus  at 
upper  margin,  causing  marked  thickening  and  puckering  of 
duodenum.       Stomach     slightly    dilated.       Posterior    gastro-en- 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  229 

terostomy  performed  and  ulcer  infolded.  Appendix  was  much 
adherent,  extremely  small,  and  fibrous;   it  was  removed. 

Re-admission  May  13,  1911.  Was  operated  upon  for  duo- 
denal ulcer  and  chronic  appendicitis  November  30,  19 10.  For 
a  time  she  had  relief,  but  soon  her  symptoms  began  again  "as 
bad  as  ever"  and  of  the  same  type,  but  the  pain  was  felt  lower 
down  in  the  abdomen,  and  referred  to  the  umbilicus.  Pain 
one  or  two  hours  after  food  and  relieved  by  food;  occasionally 
pain  to  the  right  of  the  middle  line. 

Operation  May  15,  191 1.  Incision  through  old  scar.  At 
the  lowest  part  of  the  anastomosis  was  a  hard  white  indurated 


Fig.  72. — Case  3. 

The  parts  removed.      The  gastro-enterostomy  opening  looks  downward  and  to 

the  right.      The  ulcer  is  just  seen  within  the  upper  opening. 

mass  involving  the  transverse  colon,  with  a  crater  on  it,  felt 
through  anterior  wall  of  stomach,  about  one  inch  long  and  one- 
half  inch  to  three-quarters  of  an  inch  broad,  the  whole  being 
plastered  down  by  adhesions.  After  separation,  the  crater's 
base  was  seen  to  be  formed  by  transverse  colon  and  transverse 
mesocolon;  the  edges  were  in  the  line  of  the  lowest  point  of 
the  anastomosis  between  the  stomach  and  the  jejunum  and 
involving  both  organs.  The  whole  ulcerated  area  was  cut  away. 
The  gap  in  the  anastomosis  line  was  stitched  up  by  a  row  of 
interrupted    catgut    stitches    and   one    continuous    outer   suture 


230 


ABDOMINAL   OPERATIONS. 


of  Pagenstecher  thread.  A  wide  opening  free  from  induration 
was  left  and  admitted  tw^o  fingers  easily.  In  September,  19 ii, 
the  patient  wrote  to  say  that  she  was  free  from  pain,  but  acting 
under  m}"  instructions  was  living  on  a  spare  dietar}',  consisting 
chiefl}'  of  liquids. 


Ulcer 


Lower  limb  of 
jejunum 


Stomach  covered 
by  transverse 
mesocolon 


Duodenojejuna 
flexure 


Pjq   y,. — Operation  for  Excision  of  the  Parts  ix  a  Case  of  Jejunal  Ulcer. 
Step  I.      (Drawn  by  Mr.  L.  R.  Braithwaite.) 


Fig.  74. — Operation   for  Excision  of  the   Parts   in   a    Case   of  Jejunal 

Ulcer.  Step  2. 
The  transverse  mesocolon  is  detached  from  the  stomach,  so  as  to  allow 
the  stomach  to  be  drawn  well  through  the  opening.  A  clamp  is  then  applied 
in  the  same  position  which  it  occupied  at  the  original  operation.  Clamps 
are  applied  to  the  jejunum  on  each  side  of  the  anastomosis.  (Drawn  by  Mr. 
L.  R.  Braithwaite.) 


Case  3. — Jejunal  ulcer  following  gastro-enterostomy.  Ex- 
cision. Roux's  operation.  Appendicectom}'.  Mrs.  S.  Sent 
by  Dr.  Bingham,  Lancaster.  Three  years  ago  she  had  gastro- 
enterostomy done  by  a  London  surgeon  for  duodenal  ulcer.     For 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY. 


J3I 


some  months  she  was  better,  then  began  to  have  pains  in  the 
body  soon  after  food — almost  immediately  after  swallowing  it. 
She  began  to  diet  herself  at  once,  and  has  done  so  ever  since. 
Nineteen  months  ago  she  had  a  very  severe  hsematemesis  and 
nearly  died,  and  twice  since  has  had  severe  hasmatemesis.  The 
pain,  whenever  she  fails  to  take  great  care  in  her  diet,  comes  on 
at  a  spot  about  one  inch  above  the  umbilicus,  and  may  be  very 
severe.  She  says  it  is  like  the  pain  she  had  before  the  operation. 
She  has  not  lost  weight,  but  has  carefully  dieted  herself  the  whole 


Fig.   75. — Operation    for   Excision  of  the  Parts  in  a   Case    of   Jejunal 

Ulcer.     Step  3. 
The  parts  engaged  in  the  anastomosis  with  the  ulcer  are  removed.      The 
distal  end  of  the  jejunum  is  closed.      The  proximal  end  is  open  and  is  ready 
for  union  with  the  jejunum  lower  down  in  an  end-to-side  anastomosis.      (Drawn 
by  Mr.  L.  R.  Braithwaite.) 


time.     X-ray  examination  shewed  all  food  going  through  anas- 
tomosis. 

September  11,  191 1.  Old  scar  excised  in  right  rectus.  Gas- 
tro-enterostomy  explored:  it  was  posterior  and  nearly  vertical. 
In  the  jejunum,  one-half  inch  below  the  beginning  of  the  anas- 
tomosis and  near  the  mesenteric  edge  of  it,  was  a  small  indurated 
stellate  scar,  which  was  about  the  size  of  a  three-penny  piece, 
and  by  its  contraction  caused  marked  narrowing  of  the  jejunum. 
This  was  clearly  the  scar  of  a  jejunal  ulcer.  Owing  to  the  fact 
that  a  local  incision  would  endanger  the  vascularity  of  the  jejunum 
at  this  part,  full  excision  was  performed.     The  lesser  sac  was 


232 


ABDOMINAL   OPERATIONS. 


opened  around  the  anastomosis  so  that  a  part  of  the  stomach 
was  drawn  through  and  a  clamp  put  on  above  the  anastomosis. 


\\\ft)'f  Pifr////U/i'(^ 


Fig.  76. — Operation'  for  Excision  of  the  Parts  in  a  Case  of  Jejunal  Ulcer. 

Step  4. 
The  jejunal  end-to-side  anastomosis  completed.     The  upper  closed  jejunal 
end  is  now  brought  upward  for  a  side-to-side  union  with  the  stomach.     (Drawn 
bv  Air.  L.  R.  Braithwaite.) 


Fig.  77. — Operation    for   Excision    of   the   Parts   in   a    Case  of  Jejunal 

Ulcer.     Step  5. 
The  operation  completed.      (Drawn  by  Mr.  L.  R.  Braithwaite.) 


The  jejunum  distal  to  the  anastomosis  was  clamped  and  divided 
and  the  distal  end  closed  by  suture.     The  jejunum  proximal  to 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  233 

the  anastomosis  and  to  the  ulcer  was  divided,  and,  owing  to  there 
being  a  longish  loop,  this  was  easier  than  usual,  though  even 
now  there  was  difficulty.  The  proximal  cut  end  was  anasto- 
mosed at  right  angles  to  the  distal  jejunum,  about  six  inches 
below  its  cut-and-closed  end.  The  part  of  the  jejunum  left  at- 
tached to  the  stomach  (including  the  ulcer),  together  with  the 
portion  of  the  stomach  projecting  beyond  the  clamp,  including 
therefore  the  gastro-enterostomy  opening,  was  excised. 

The  length  of  jejunum  formerly  distal  to  the  anastomosis, 
whose  cut  end  had  already  been  closed,  was  now  clamped,  and 
a  side-to-side  union  effected  between  it  and  the  opening  in  the 
stomach  embraced  by  the  clamp.  The  appendix  was  adherent 
and  was  removed.  The  original  duodenal  ulcer  was  well  marked 
and  was  infolded  and  covered  in  by  omentum. 

Case  4. — Transgastric  excision  of  a  gastrojejunal  ulcer.  The 
patient,  a  male,  aged  forty- seven,  had  a  history  of  abdominal 
trouble  extending  over  seven  years.  At  the  commencement  his 
only  symptom  was  epigastric  pain  on  kneeling,  on  leaning  for- 
wards, in  fact,  after  any  movement  which  caused  contraction 
of  his  recti  abdominis.  Gradually  this  pain  became  more  se- 
vere, occurring  at  almost  regular  intervals,  and  accompanied 
by  flatulence  and  hyperacidity.  The  pain  was  a  typical  hunger 
pain,  commencing  from  two  to  three  hours  after  meals,  and  was 
relieved  by  lying  down  or  by  taking  food.  There  was  never  any 
vomiting.  The  epigastric  pain  was  situated  above  and  to  the 
right  of  the  umbilicus,  and  occurred  only  at  intervals.  Gradu- 
ally, however,  the  intervals  became  shorter  and  the  periods  of 
pain  longer. 

After  three  and  a  half  years  of  this  he  had  a  sudden  attack 
of  severe  abdominal  pain  in  the  right  hypochondrium,  which 
was  diagnosed  as  a  subacute  perforation;  from  this  he  recovered. 

In  January,  191 2,  a  posterior  gastro-enterostomy  was  per- 
formed by  another  surgeon.  The  patient  recovered  from  this 
operation,  and  his  symptoms  subsided  only  to  return  about  eight 
months  later.  The  pain  after  this  was  lower  in  the  abdomen  and 
more  to  the  left  than  previously — this  pain  was  really  the  only 
symptom,  but  it  was  severe  in  character  and  for  the  last  few  weeks 
before  I  saw  the  patient  almost  constant  in  duration. 

The  :K-ray  report  was  as  follows:    "The  bismuth  food  passes 


234 


ABDOMIXAL    OPERATIONS. 


freely  through  the  oesophagus.  The  stomach  is  not  dilated. 
The  outline  is  regular  except  for  an  indentation  about,  the  middle 
of  the  greater  curvature.  Peristalsis  is  seen,  but  it  is  not  excessive. 
The  gastro-enterostomy  opening  is  patent,  and  as  far  as  I  can 
judge  about  two-thirds  of  the  food  passes  through  it  and  about 
one-third    through    the    pAdorus.     The    stomach   is    empt}'    two 


Fig.  78. — Transgastric  excision  of  jejunal  ulcer. 


hours  after  the  meal.  No  food  lodges  in  the  duodenum,  nor  is 
there  any  duodenal  kinking.  The  small  intestine  is  empt}'  in 
twelve  hours.     No  stasis.     No  ileal  kink. 

"In  twenty-four  hours  almost  all  the  bismuth  food  has  been 
passed  per  rectum.  I  have  seen  no  abnormality  in  the  large 
intestine. 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  235 

"There  is  no  x-Tay  evidence  of  calculus  in  either  kidney,  in 
the  ureters,  or  in  the  bladder." 

On  January  7,  1914,  I  reopened  the  abdomen,  excising  the 
scar  of  the  previous  operation,  and  adopting  for  the  deeper 
portions  of  the  incision  Crile's  aneesthesia.  On  opening  the  ab- 
domen the  transverse  colon  presented:  it  was  markedly  hyper- 
trophied  and  distended.  It  was  kinked  in  a  very  curious  fashion, 
its  middle  portion  being  adherent  to  the  under  surface  of  the  left 
lobe  of  the  liver  and  to  the  diaphragm.  Before  the  stomach 
could  be  examined,  it  was  necessary  to  separate  the  adhesions, 
fixing  the  colon  in  this  unusual  position.  This  separation  was 
exceedingly  difficult.  The  stomach  itself  was  normal  in  outline, 
and  there  was  a  scar  of  an  old  ulcer  on  the  first  stage  of  the  duo- 
denum. The  anastomosis  which  had  been  performed  was  a 
posterior  vertical  no-loop  gastro-enterostomy.  The  stoma  was 
of  adequate  size  and  in  the  correct  position.  On  feeling  the  stoma 
with  the  finger  a  hard  nodule,  the  size  of  a  shilling,  with  a  dimple 
in  its  centre,  could  be  detected.  This  nodule,  which  was  thought 
to  be  a  gastrojejunal  ulcer,  could  be  clearly  palpated  through 
the  anterior  wall  of  the  stomach.  In  view  of  the  technical  per- 
fectness  of  the  original  operation,  it  was  decided  that  a  trans- 
gastric  excision  of  the  ulcer  would  be  a  safer  operation  than  an 
excision  of  the  entire  anastomosis.  Accordingly,  while  my  as- 
sistant passed  two  fingers,  one  on  either  side  of  the  jejunal  loop 
so  as  to  grip  the  ulcer,  I  made  a  longitudinal  incision  through  the 
anterior  wall  of  the  stomach,  parallel  to  the  curvatures  and  mid- 
way between  them.  On  opening  the  stomach  my  assistant 
everted  the  posterior  wall  through  the  opening,  thus  bringing  the 
gastrojejunal  ulcer  into  view.  The  ulcer  was  almost  entirely 
gastric,  being  just  on  the  edge  of  the  stoma.  On  opening  the 
stomach  a  piece  of  silk  (or  linen  thread)  was  found  hanging  loose 
from  the  region  of  the  ulcer. 

Excision  was  performed  with  scissors,  and  the  opening  made 
in  the  posterior  wall  of  the  stomach  closed  with  through-and- 
through  sutures  passed  from  the  mucosa. 

The  anterior  incision  was  then  closed,  leaving  only  room  for 
a  No.  14  rubber  catheter,  which  was  passed  into  the  stomach  and 
along  the  afferent  jejunal  loop. 

After  the  closure  of  the  anterior  incision  a  few  interrupted 
Lembert  sutures  were  passed  posteriorly  in  the  region  of  the  orig- 


236  ABDOMINAL   OPERATIONS. 

inal  anastomosis.  The  abdomen  was  then  closed,  leaving  the 
catheter  in  situ.  The  patient  was  given  4  ounces  of  peptonised 
milk  through  the  gastrostomy  tube  on  leaving  the  table. 

The  following  case,  in  which  there  were  two  separate  per- 
forations of  peptic  ulcers  in  the  jejunum,  is  recorded  by  Battle 
("Lancet,"  vol.  i,  1905,  p.  1246): — - 

The  patient,  a  woman,  aged  30,  w^as  admitted  to  St.  Thomas's 
Hospital  in  March,  1903.  The  ulcer  was  situated  in  the  anterior 
aspect  of  the  stomach  near  the  pylorus  and  was  surrounded  by 
a  good  deal  of  thickening.  It  was  sutured,  the  peritoneum 
was  cleansed,  and  a  drainage  tube  was  left  in  the  lower  wound. 
Anterior  gastro-enterostomy  was  performed  on  April  9,  1904, 
for  pyloric  stenosis.  On  May  6,  1905,  she  underwent  operation 
for  perforation  of  a  simple  ulcer  of  the  jejunum  which  had  burst 
into  the  general  peritoneal  cavity.  It  was  a  circular  clean-cut 
ulcer,  situated  about  one  and  a  half  inches  from  the  line  of  junc- 
tion of  the  bowel  with  the  stomach.  The  ulcer  was  sutured, 
the  peritoneum  was  cleansed,  and  the  two  wounds  through  which 
this  was  done  were  closed  without  drainage.  Finally,  the  pa- 
tient was  again  admitted  to  the  hospital  on  ]\Iarch  14,  1906,  for 
symptoms  of  perforation.  At  the  operation  a  perforated  ulcer 
was  found  at  the  line  of  junction  of  the  stomach  and  small 
intestine.  The  tissues  around  it  were  indurated.  She  left  the 
hospital  on  April  12th,  having  made  a  very  satisfactory  recovery. 
It  was  of  interest  to  note  that  there  were  no  adhesions  found  at 
this  operation ;  also  that  there  was  now  no  hernial  protrusion  of 
any  of  the  scars. 

7.  The  question  of  chest  complications,  parotitis,  etc.,  is 
discussed  elsewhere. 

8.  Diarrhoea. — -An  occasional  sequel  to  the  operation  of 
gastro-enterostomy  is  the  occurrence  of  diarrhoea.  The  attack 
may  be  slight,  or  may  be  so  serious,  so  constant,  uncontrollable 
and  exhausting  as  to  be  the  immediate  cause  of  death. 

It  has  been  in  my  own  experience  extremely  infrequent,  and 
when  noticed  has  been  temporary  and  never  alarming  or  serious. 
In  only  one  case  have  special  measures,  dieting  and  the  admin- 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  237 

istration  of  opium,  been  necessary;  the  patient,  a  man  of  forty- 
six,  was  operated  upon  for  duodenal  ulceration,  with  recent  ex- 
cessive haemorrhages.  The  diarrhoea  lasted  for  five  days,  but, 
although  troublesome,  was  never  so  unremitting  as  to  give 
me  any  real  anxiety  as  to  the  patient's  ultimate  recovery. 

Much  more  serious  experiences  are  recorded  by  others. 
Kelling  ("Archiv  f.  Klin.  Chir.,"  Bd.  62,  1900)  and  Anschlitz 
("Mitth.  a.  d.  Grenzgebiet, "  Bd.  15,  1905,  p.  305)  have  dealt 
with  the  subject  in  detail. 

Kelling  remarks  that  in  the  cases  which  prove  fatal  no  obvious 
explanation  of  the  diarrhoea,  is  discoverable.  He  suggests  that 
there  are  two  forms :  First,  that  in  which  the  diarrhoea  is  due  to 
the  escape  into  the  intestine  of  acid  contents  not  neutralised 
by  the  bile  and  the  pancreatic  juice.  Second,  that  in  which  it 
is  due  to  "fermentation."  The  latter  is  not  serious,  and  is 
seen  only  or  chiefly  in  patients  suffering  from  carcinoma,  or 
in  those  cases  where  there  is  an  absence  of  free  HCl. 

The  explanation  of  the  first  form  lacks  adequate  confirmation. 
In  spite  of  the  fact  that  both  bile  and  pancreatic  juice  may  al- 
most constantly  be  found  in  the  stomach  after  gastro-enteros- 
tomy,  acid  contents  may  still  escape  into  the  intestine,  and  may 
indeed  cause  peptic  ulcer.  But  it  has  not  been  suggested,  or 
recognised,  that  diarrhoea  occurs  especially  in  those  suffering 
from  hyperchlorhydria,  as  one  would  expect  if  this  hypothesis 
were    accurate. 

With  regard  to  the  explanation  of  the  second  form,  this 
may  be  true  in  certain  cases.  Fermentation  may  go  on  to  such 
a  degree  in  the  stomach  that  no  amount  of  careful  lavage  will 
ensure  the  cleanliness  of  the  mucosa.  This  may  be  proved  by 
examining  a  pyloric  growth  after  pylorectomy  has  been  performed ; 
the  recesses  of  the  irregular  mass  are  sometimes  extremely  foul. 
The  delivery  of  putrid,  fermenting  food  into  the  jejunum  would, 
of  course,  instantly  set  up  diarrhoea.  It  is  always  remarked 
that  the  stools  in  such  a  case  are  "very  oft'ensive. "  But  in  not 
a  few  cases  the  diarrhoea  does  not  appear  at  once,  but  only 


238  ABDOMINAL  OPERATIONS. 

after  several  da^'s,  Avhen  the  patient  has  perhaps  been  doing  Avell. 
It  should  also  be  remarked  that  cases  have  occurred  after  partial 
gastrectomy,  when  the  infective  area  has  been  removed. 

Anschiitz  believes  the  chief  cause  to  be  the  excessive  weakness 
of  the  patient,  and  remarks  that  the  same  type  of  diarrhoea 
is  seen  in  those  who  suffer  from  advanced  carcinoma  elsewhere, 
or  from  extensive  tuberculous  disease  apart  from  intestinal 
lesions.  Carle  and  Fantino  remark  that  the  food  runs  through 
the  intestine  like  water  through  a  rubber  tube,  which  is  pOAver- 
less  to  hasten  or  impede  its  progress. 

It  is  apparent  that  no  adequate  explanation  of  this  com- 
plication can  be  given ;  but  it  is  probable  that  a  strict  attention 
to  the  diet,  the  administration  of  only  sterile  foods  for  some  time 
after  the  operation,  the  giving  of  opium  early,  and  the  exhibition 
of  drugs  such  as  isoform,  ;3-naphthol,  salol,  etc.,  whose  purpose 
is  to  act  as  disinfectants,  will  comprise  the  most  effective  means 
at  our  disposal  for  preventing  and  for  checking  the  onset  of  this 
symptom. 

A.  F.  Hertz  ("Annals  of  Surgery,"  October,  1913)  mentions 
additional  unfavourable  complications  after  gastro-enterostomy, 
namely,  too  rapid  drainage  of  the  stomach,  and,  in  cases  of  dila- 
tation, situation  of  the  stoma  above  the  upper  level  of  the  gas- 
tric contents. 

Where  there  is  too  rapid  drainage  of  the  stomach,  the  patient 
complains  of  a  sensation  of  fulness,  localised  rather  lower  than 
the  position  where  the  pain  of  the  original  ulcer  was  felt ;  there  is 
usually  diarrhoea  also,  the  bowels  in  some  cases  being  opened  after 
each  meal.     Hertz  writes: 

"In  all  patients  suffering  from  this  group  of  symptoms  I 
have  found  with  the  x-rays  that  the  stomach  was  small  and  hy- 
pertonic, and  that  the  passage  of  food  out  of  it  was  extremely 
rapid,  so  that  a  meal  consisting  of  half  a  pint  of  porridge  and 
milk,  mixed  with  two  ounces  of  bismuth  oxy chloride  or  barium 
sulphate,  left  the  stomach  in  less  than  an  hour,  and  in  one  case  in 
less  than  ten  minutes  after  being  taken,  instead  of  requiring  the 


COMPLICATIONS   AFTER   GASTRO-ENTEROSTOMY.  239 

normal  three  or  four  hours.  If  the  patient  is  watched  while  he  is 
taking  the  meal,  the  outflow  from  the  stoma  may  indeed  appear 
to  be  almost  as  rapid  as  the  inflow  from  the  oesophagus." 

He  adds  that  these  appearances  were  seen  both  in  cases  where 
the  pylorus  was  closed  and  where  it  was  patent;  indeed,  in  one 
case  pyloroplasty  had  been  performed.  The  feeling  of  distension 
is  doubtless  due  to  the  rapid  passage  of  the  gastric  contents 
through  the  stoma,  leading  to  abnormal  distension  of  the  proximal 
portion  of  the  jejunum.  The  diarrhoea  is  due  to  the  irritation  of 
the  bowels  by  the  food  which  escapes  from  the  stomach  too  rap- 
idly for  efficient  gastric  digestion. 

Treatment  in  cases  such  as  this  must  be  either  palliative — ■ 
i.e.,  rest  for  an  hour  after  food  to  delay  the  emptying  of  the 
stomach,  combined  with  pancreatic  extract  to  compensate  for 
the  deficiency  of  the  normal  secretion,  and  possibly  small  doses 
of  belladonna  to  relieve  the  jejunal  spasm  set  up  by  distension, 
or  operative,  i.e.,  narrowing  of  the  stoma.  Another  possible 
cause  of  trouble  is  situation  of  the  stoma  above  the  level  of  the 
gastric  contents.  In  cases  of  gastric  dilatation  it  often  takes  con- 
siderable time  to  ascertain  which  portion  of  the  stomach  will  lie 
lowest  when  the  upright  posture  is  assumed.  These  cases  usu- 
ally improve  with  rest  in  bed,  which  allows  the  stomach  to  re- 
gain its  tone,  and  also  aids  the  emptying  in  cases  where  the 
stoma  is  not  sufficiently  low. 

My  own  experience  shews  that  the  unsatisfactory  results 
which  follow  upon  gastro-enterostomy  are  due  (apart  from  tech- 
nical errors)  almost  exclusively  to  the  performance  of  the  operation 
in  improper  cases.  If  the  operation  is  restricted  to  those  cases  in 
which  definite  organic  disease  is  discovered  in  the  stomach,  distal 
to  the  suggested  anastomosis,  or  in  the  duodenum,  the  results  are 
uniformly  satisfactory.  Bad  results  are  due  to  the  adoption  of 
the  operation  in  cases  where  no  lesion  is  present  to  justify  it. 


CHAPTER  XIII. 

OPERATIONS  FOR  CHRONIC  GASTRIC  ULCER. 
GASTRODUODENOSTOMY. 

The  operation  of  gastroduodenostomy  was  first  suggested 
by  Jaboulay  in  1892,  and  performed  by  him  in  1894.  In  1895 
Kiimmell  independently  suggested  the  same  principle,  the  union 
of  the  duodenum  to  the  stomach,  but  carried  the  principle  out 


Fig.  79. — Gastroduodenostom}-    lines  of  incision  (J aboulay's  method). 

by  dividing  the  duodenum  completely  across,  closing  the  proxi- 
mal end,  and  transplanting  the  distal  end  into  the  anterior  wall 
of  the  stomach  near  the  greater  curvature. 

Jaboulay  united  the  anterior  wall  of  the  duodenum  to  the 
anterior  wall  of  the  stomach,  folding  the  duodenum  forward 
over  a  hinge,  as  it  were,  formed  by  the   pylorus.     Yillard   de- 

240 


GASTRODUODENOSTOMY. 


241 


scribed  a  modification  of  the  method  under  the  term  "subpyloric 
gastroduodenostomy."  Instead  of  folding  the  duodenum  over 
on  to  the  stomach,  he  anastomosed  the  contiguous  surfaces  of 
the   stomach   and   duodenum. 

The  operation  is  most  easily  performed  when  there  is  a  largely 
dilated  stomach  and  a  mobile  duodenum.     In  one  case  reported 


Fig.   80. — Gastroduodenostomy  (Ktiinmeirs  method). 


by  Spencer  any  other  gastro-intestinal  anastomosis  was  im- 
possible by  reason  of  extensive  adhesions  which  affected  all  of 
the  pyloric  portion  of  the  stomach.  When  the  pyloric  region 
is  adherent  or  invaded  by  growth,  the  operation  is  difhcult  or 
may  be  impossible. 

The  advantages  of  this   procedure   over  gastrojejunostomv 
are  claimed  to  be  the  easier  emptying  of  the  stomach  at  an  ori- 


VOL.  I — 10 


242 


ABDOMINAL    OPERATIONS. 


fice  near  the  natiiral  outlet,  and  the  absence  of  bile  regurgita- 
tion, owing  to  the  fact  that  the  new  opening  in  the  intestine  is 
placed  above  the  bile  papilla.  The  regurgitation  of  bile  does, 
however,  occur  if  a  large  opening  be  made. 

The  two  methods  of  performing  an  anastomosis  between 
the  stomach  and  duodenum  which  enable  the  operation  to  be 
most  satisfactority  completed  are  those  described   by  Kocher 


Fig.   81. — Gastroduodenostomy  (Yillard's  method). 


and  Finney.  Professor  Kocher  has  suggested  that  the  duo- 
denum should  be  freed  by  stripping  up  the  peritoneum 
to  the  right  of  the  vertical  (second)  portion,  so  that  an  anas- 
tomosis between  the  stomach  and  the  duodenum  may  be  more 
readily  performed.  The  following  description  is  given  by  Pro- 
fessor Kocher  ("Scott.  Medical  and  Surgical  Journal,"  October, 
1903,  p.  311): 


GASTRODUODENOSTOMY.  243 

"The  most  suitable  incision  is  one  similar  to  that  which  we 
recommend  for  exposing  the  gall-bladder,  viz.,  an  oblique  in- 
cision two  finger-breadths  below  and  parallel  to  the  right  cos- 
tal margin,  beginning  at  the  middle  line.  After  dividing  the 
skin  and  fascia,  the  rectus  muscle  is  cut  through  as  far  as  the 
broad  abdominal  muscles.  The  posterior  layer  of  the  rectal 
sheath,  the  fascia  trans versalis,  and  the  peritoneum  are  divided. 
In  muscular  subjects  the  transversalis  muscle  is  split  parallel 
to  its  fibres,  which  are  then  firmly  drawn  apart.  Should  any 
adhesions  exist  between  the  gall-bladder  and  the  colon,  they 
must  be  divided.  The  liver  is  drawn  upwards,  the  stomach  to 
the  left,  and  the  transverse  colon  and  the  descending  limb  of 
the  hepatic  flexure  downwards.  The  duodenum  is  then  brought 
into  view,  and  its  outer  border  is  clearly  defined.  A  pad  of  gauze 
is  placed  against  the  under  surface  of  the  liver,  and  the  latter 
is  then  drawn  well  upwards  with  a  suitable  retractor.  Gauze 
compresses  are  also  employed  to  push  aside  the  stomach  and 
colon. 

"The  delicate  layer  of  parietal  peritoneum  covering  the  kid- 
ney is  divided  vertically  i^  inches  external  to  the  second  part 
of  the  duodenum,  and  the  incision  is  then  continued  vertically 
downwards  through  the  upper  layer  of  the  transverse  meso- 
colon (which  is  held  on  the  stretch)  as  far  as  the  larger  branches 
of  the  vessels.  The  fingers  are  then  introduced  behind  the  left 
edge  of  the  incision  through  the  peritoneum,  and  the  duodenum  is 
separated  from  the  vertebral  column,  the  vena  cava,  and  the  aorta 
until  it  can  be  brought  forward  and  pressed  against  the  pyloric 
portion  of  the  stomach,  which,  in  its  turn,  is  compressed  against 
the  left  edge  of  the  wound  in  the  abdominal  wall,  so  as  to  shut 
off  the  general  cavity  of  the  stomach  and  prevent  escape  of  its 
contents.  Both  stomach  and  duodenum  are  now  compressed 
above  and  below  between  the  fingers  of  an  assistant,  and  the 
lateral  anastomosis  is  effected  in  the  usual  manner  by  two  rows 
of  sutures. 

"To  one  who  has  once  convinced  himself  how  easily  and 
securely  this  lateral  gastroduodenostomy  can  be  performed — 
provided  the  duodenum  can  be  rendered  sufficiently  movable — 
it  will  be  evident  how  admirably  the  operation  fulfils  the  indi- 
cations for  treatment  in  stenosis  of  the  pylorus.  Unlike  the 
other  surgeons   who   have   performed   gastroduodenostom}^   we 


244  ABDOMINAL  OPERATIONS. 

do  not  limit  the  operation  to  special  cases:  on  the  contrarv% 
we  regard  it  as  the  normal  procedure,  and  we  are  of  the  opinion 
that  it  will  take  precedence  over  all  the  previous  methods  of 
gastro-enterostom}^  and  pyloroplasty. 

"The  method  is  subject  to  only  one  contraindication,  viz., 
the  presence  of  such  extensive  adhesions  to  the  under  surface 
of  the  hver  that  the  duodenum  cannot  be  sufficient^  freed.  This 
difficulty  of  adhesions  can,  however,  often  be  overcome,  as  we 
have  proved  in  three  of  our  cases ;  but  the  fact  of  having  to  per- 
form the  suturing  inside  the  abdomen  is  apt  to  interfere  with 
the  security  of  the  stitching,  especially  in  difficult  cases.  It 
is  on  this  accoimt  that  subpyloric  gastroduodenostomy  did  not 
meet  with  universal  acceptance.  The  subpyloric  portion  of 
the  duodenum  cannot  be  drawn  out  of  the  wound  on  account 
of  its  connexion  with  the  gastrohepatic  omentum  and  the  im- 
portant structures  contained  within  it.  This  fixation  to  the 
under  surface  of  the  liver  may  be  so  firm  that  onty  the  lower 
two-thirds,  or  only  the  lower  part,  of  the  vertical  portion  of 
the  duodenum,  together  with  the  inferior  flexure,  can  be  brought 
in  contact  with  the  stomach. 

"We  therefore  propose  that,  instead  of  Villard's  subp3doric 
gastroduodenostomy,  the  name  lateral  gastroduodenostomy  be 
given  to  this  operation,  to  distinguish  it  from  our  method  of 
inserting  the  divided  duodenum  into  the  posterior  wall  of  the 
stomach  after  resection  of  the  pylorus.  The  great  difference 
between  Villard's  subpyloric  gastroduodenostomy  and  our  pro- 
cedure is  that  we  render  the  descending  portion  of  the  duodenum, 
the  inferior  flextu-e,  and  a  considerable  portion  of  the  third  (trans- 
verse) part  so  movable  that  the  parts  to  be  sutured  can  readily 
be  raised  up  and  surrounded  with  gauze,  so  that  the  sutures  can 
be  introduced  extraperitoneal^  with  comfort  and  security. 

"We  intend  in  future  to  perform  lateral  gastroduodenos- 
tomy in  all  cases  of  stricture  of  the  p3dorus,  and  only  to  have 
recourse  to  gastrojejunostomy  in  cases  rendered  unusually  dif- 
ficult by  firm  adhesions.  We  have  performed  the  operation 
on  five  occasions — four  times  for  cicatricial  stenosis  and  once 
for  malignant  stricture.  The  results  have  been  convincing. 
Regurgitation  of  bile  either  does  not  occur  at  all  or  only  at  first, 
when  a  large,  gaping  opening  has  been  made.  It  is  advisable 
to  make  the  anastomotic  opening  as  high  as  possible,  and  not 


GASTRODUODENOSTOMY.  245 

too  large.  The  patient  with  carcinoma  was  at  once  relieved  of 
all  her  discomfort.  Onty  one  patient  complained  subsequently 
of  very  severe  pain,  and  he  had  a  simultaneous  cholecystotomy 
performed  for  gall-stones.  That  a  dilated  and  sacculated 
stomach  is  not  so  well  emptied  as  by  our  inferior  gastrojejunos- 
tomy is  obvious.  If  gastroduodenostomy  be  performed  in  such 
a  case,  it  is  advisable  to  occasionally  wash  out  the  stomach." 

Finney's  operation  was  described  by  its  originator  as  "  a 
new  method  of  p^doroplasty."  I  am  indebted  to  Dr.  Finney 
for  the  following  description  of  his  operation,  and  for  the  privi- 
lege of  being  allowed  to  witness  its  performance  by  him  at  the 
Johns  Hopkins  Hospital. 

The  operation  is  as  follows: 

"  Divide  the  adhesions  binding  the  pylorus  to  the  neighbour- 
ing structures;  also  free  as  thoroughly  as  possible  the  pyloric 
end  of  the  stomach  and  first  portion  of  the  duodenum.  Upon 
the  thoroughness  wdth  which  the  pylorus,  lower  end  of  the 
stomach,  and  upper  end  of  the  duodenum  are  free  depends,  in 
large  measure,  the  success  of  the  operation  and  the  ease  and 
rapidity  of  its  performance.  I  wish  to  emphasise  this  as  one 
of  the  most  important  points  in  the  operation.  Frequently, 
at  first  sight,  the  pylorus  may  seem  hopelessly  bound  down, 
when,  after  a  little  patient  toil  and  judicious  use  of  the  scalpel 
and  blunt  dissector,  it  is  found  that  it  can  be  freed  with  com- 
parative ease.  A  suture,  to  be  used  as  a  retractor,  is  taken  in 
the  upper  wall  of  the  pylorus,  which  is  then  retracted  upwards. 
A  second  suture  is  then  inserted  into  the  anterior  wall  of  the 
stomach,  and  a  third  into  the  anterior  wall  of  the  duodenum,  at 
equidistant  points — say  about  12  cm. — from  the  suture  just  de- 
scribed in  the  pylorus.  These  second  sutures  mark  the  lower  ends 
of  the  gastric  and  duodenal  incisions  respectively.  They  should 
be  placed  as  low  as  possible  in  order  that  the  new  pylorus  may 
be  amply  large.  Traction  is  then  made  upwards  on  the  py- 
loric suture,  and  downwards  in  the  same  plane,  on  the  gastric 
and  duodenal  sutures.  This  keeps  the  stomach  and  duodenal 
walls  taut,  and  allows  the  placing  of  the  sutures  with  greater 
facility  than  if  the  walls  remained  lax.  The  peritoneal  surfaces 
of  the  duodenum  and  stomach,  along  its  greater  curvature,  are 


246 


ABDOMINAL   OPERATIONS. 


Fig.  82. — Finney's  operation.     The  duodenum  and  stomach  are  clamped.      The 

line  of  incision  is  shewn. 


Fig.  83. — Finney's  operation.     The  first  line  of  suture  complete,  the  stomach 
and  duodenum  opened,  and  the  inner  suture  commenced. 


GASTRODUODENOSTOMY. 


247 


Fig.   84. — Finney's  operation.      The  inner  suture  nearly  completed. 


Fig.   85. — Finney's  operation.      The  outer  suture  completed. 


248 


ABDOMINAL   OPERATIONS. 


then  sutured  together,  as  far  posteriorly  as  possible.  For  this 
row  I  would  recommend  the  use  of  the  continuous  suture,  as 
it  is  more  easily  and  quickly  applied,  and  it  can  be  reinforced 
after  the  stomach  and  duodenum  have  been  incised.  After  the 
posterior  line  of  sutures  has  been  placed,  an  anterior  row  of  mat- 
tress sutures  is  taken,  which  are  not  tied,  but  left  long,  in  the 


Fig.  86. — Finney's  operation.     A  flap  turned  upwards  to  shew  the  alteration  in 
the  parts  produced  by  the  anastomosis  (after  Sinclair  White). 


manner  indicated.  These  sutures,  after  they  have  been  placed, 
are  retracted  vertically  in  either  direction  from  the  middle  of 
the  portion  included  in  the  row  of  sutures.  Then,  after  all  the 
stitches  have  been  placed  and  retracted,  the  incision  is  made 
in  the  shape  of  a  horseshoe.  The  sutures  should  be  placed  far 
enough  apart  to  give  ample  room  for  the  incision.  The  gastric 
arm  of  the  incision  is  made  through  the  stomach-wall  just  in- 


GASTRODUODENOSTOMY.  249 

side  the  lowest  point  of  the  Hne  of  sutures,  and  is  carried  up  to 
and  through  the  pylorus  and  around  into  the  duodenum,  down 
to  the  corresponding  point  on  the  duodenal  side.  Haemor- 
rhage is  then  stopped.  It  is  well  to  excise  as  much  as  possible 
of  the  scar  tissue  upon  either  side  of  the  incision  in  order  to  limit, 
as  far  as  possible,  the  subsequent  contraction  of  the  cicatrix. 
This  procedure  I  carried  out  in  two  of  my  cases  with  great  satis- 
faction, and  I  should  strongly  recommend  it  in  all  cases  where 
the  walls  of  the  pylorus  are  much  thickened  and  there  is  much 
scar  tissue  present.  It  is  well,  too,  to  trim  off  with  scissors  redund- 
ant edges  of  mucous  membrane,  in  order  to  prevent  the  formation 
of  a  valve-like  fold  of  mucous  membrane  at  the  new  pylorus. 
A  continuous  catgut  suture  is  now  taken  through  and  through 
all  the  coats  of  the  intestine  on  the  posterior  side  of  the  incision. 
This  reinforces  the  posterior  line  of  sutures,  secures  better  ap- 
proximation of  the  cut  edges  of  the  mucous  membrane,  and  pre- 
vents the  reunion  of  the  divided  intestinal  walls.  The  anterior 
sutures  are  then  straightened  out  and  tied,  and  the  operation  is 
complete,  unless  one  wishes  to  reinforce  the  mattress  sutures 
with  a  few  Lembert  stitches.  This  procedure,  as  is  readily  seen, 
gives  the  minimum  of  exposure  of  infected  surface.  All  the 
stitches  are  placed  and  the  posterior  row  tied  before  the  bowel 
is  opened,  and  it  remains  open  just  long  enough  to  control  the 
haemorrhage.  The  size  of  the  newly  formed  pyloric  opening 
is  limited  in  this  operation  only  by  the  mobility  of  the  stomach 
and  duodenum  and  the  judgment  of  the  operator. 

' '  In  all  of  my  cases  the  incision  has  been  about  1 2  cm.  in  length, 
and  could  have  been  made  longer  had  I  chosen  to  make  it  so. 
Unless  the  stomach  is  very  much  dilated  or  has  descended  to  an 
unusual  extent,  the  lower  limit  of  the  new  outlet  is  at  or  near 
the  level  of  its  most  dependent  portion." 

I  have,  when  performing  Finney's  operation,  modified  this 
method  of  performing  it.  I  have,  in  fact,  applied  to  the 
operation  of  gastroduodenostomy  the  method  adopted  in  the 
operation  of  gastro-enterostomy ;  that  is  to  say,  I  have  applied 
clamps  to  the  stomach  and  to  the  duodenum,  and  from  both  these 
viscera  a  large  ellipse  of  the  mucous  membrane  has  been  ex- 
cised after  division  of  the  serous   and   subserous   coats.     The 


250 


ABDOMINAL   OPERATIONS. 


Fig.  8  7 . — -Gastroduodenostomy ;  shewing  the  parts  to  be  embraced  by  the  clamp . 


V 


Fig.   8.S. — Gastroduodenostomy;   the  parts  embraced  by  the  clamps   and   the 
position  of  the  anastomotic  opening. 


GASTRODUODENOSTOMY. 


251 


clamps  prevent  hcemorrhage  and  the  escape  of  fluids  from  the 
stomach  and  duodenum,  and  thereby  make  the  operation  speedier 
and  simpler. 

For  this  operation  I  have  had  made  a  special  form  of  clamp, 
the  blades  of  which  at  their  origin  are  sharply  bent  at  a  right 
angle.  The  duodenum,  even  after  be- 
ing "mobilised,"  cannot  always  be 
brought  easily  to  the  surface ;  but  with 
this  clamp  the  bowel  can  be  well  secured, 
because  the  blade  lies  well  within  the 
abdomen,  when  the  handle  lies  flat 
upon  the  surface. 

The  operation  of  pyloroplasty  has 
fallen  into  almost  complete  disuse. 
Even  in  the  hands  of  its  warmest  ad- 
vocates it  was  an  unsatisfactory  opera- 
tion, and  the  number  of  cases  in  which 
there  was  a  recurrence  of  symptoms  was 
very  large. 

The  operation  of  Finney  and  the 
operation  of  Kocher  have,  however,  a 
distinct  place  in  surgery,  and  it  is  by 
no  means  unlikely  that  in  the  future 
they  will  be  performed  in  a  certain  class 
of  cases  for  which  gastro-enterostomy  is 
now  the  chosen  method.  It  has  seemed 
to  me  that  in  those  cases  where 
pyloric  spasm  is  a  prominent  condition, 
where  it  is  caused  by  ulceration  in  active 
progress  at  a  point  a  little  distant 
from  the  pylorus,  Finney's  operation  will  be  especially  of  ser- 
vice. In  the  ordinary  case  of  pyloric  stenosis,  with  dilatation 
and  hypertrophy  of  the  stomach,  no  operation  could  be  more 
satisfactory  than  posterior  gastro-enterostomy;  for  these  cases 
it  is  hardly  possible  that  it  can  ever  be  replaced  by  an  opera- 


Fig.  89. — Moynihan's 
clamp  for  use  in  Finnej^'s 
operation  and  partial  gas- 
trectomy. 


252  ABDOMINAL   OPERATIONS. 

tion  which  is  easier,  speedier,  or  safer.  In  cases  of  active  ulcera- 
tion and  pyloric  spasm  it  is  probable  that  Finney's  operation 
will  prove  to  be  of  great  value. 

In  certain  cases  of  hour-glass  stomach  a  modification  of 
Finney's  operation  may  be  used,   as  suggested  by  Kammerer. 

GASTRO-ENTEROSTOMY  COMBINED  WITH  JEJUNOSTOMY. 

I  have  performed  jejunostomy  after  the  method  of  Witzel's 
gastrostomy  in  combination  with  the  modified  Roux  operation 
in  five  instances,  for  cases  of  large  chronic  gastric  ulcer  surrounded 
b}"  inflammatory  tissue  and  adherent  to  the  pancreas.  Two  of 
these  have  been  reported  for  me  b^'  E.  T.  Tatlow  C' Lancet," 
November  23,  1912): 

"Case  i. — The  patient,  a  female,  aged  sixt}^  had  an  anterior 
gastro-enterostomy  in  Y  performed  two  years  ago.  At  the  oper- 
ation a  large  circular  ulcer  was  foimd  on  the  posterior  surface  of 
the  stomach  near  the  greater  curvature,  adherent  posteriorly  to 
the  pancreas.  For  some  three  months  after  operation  the  pain 
disappeared.  The  woman  was  readmitted  to  hospital  in  the  mid- 
dle of  March,  1912,  complaining  of  continuous  epigastric  pain, 
worse  immediate^  after  food.  She  lived  on  milk  and  'slops,' 
vomited  frequently,  and  starved  herself  for  four  or  five  days  at  a 
time ;  she  was  losing  weight  rapidly.  At  the  operation  in  ]March 
the  previous  anterior  anastomosis  was  found  to  be  patent,  whilst 
the  ulcer  was  as  large  as  at  the  original  operation.  Jejunostomy 
was  performed,  the  jejunum  being  opened  at  a  point  about  two 
inches  above  the  fork  of  the  Y  anastomosis,  in  that  portion  of  the 
bowel  coming  from  the  duodenojejunal  flexure,  the  catheter 
being  retained  in  position  by  the  method  described  below.  So  far 
the  results  of  this  operation  have  been  highly  satisfactor\\  For 
six  months  the  woman  fed  herself  through  her  jejunal  tube,  she 
enjoyed  complete  freedom  from  pain,  and  has  put  on  weight. 
For  the  past  two  months  she  has  been  gradually  resuming  feed- 
ing by  the  mouth. 

"  Case  2. — The  patient,  a  female,  aged  fifty-eight,  had  an  an- 
terior gastro-enterostomy  in  Y  performed  three  years  ago.  At 
the  operation  a  large  gastric  ulcer  was  found  on  the  posterior 


GASTRODUODENOSTOMY. 


253 


surface  of  the  stomach,  bound  firmly  down  to  the  liver  and  pan- 
creas. For  twelve  months  after  the  operation  her  digestion  im- 
proved, but  later  her  symptoms  returned.  Twenty  weeks  be- 
fore her  readmission  to  hospital  in  Leeds,  she  was  operated  upon 
elsewhere  for  a  subacute  perforation.  She  came  back  to  the  In- 
firmary on  September  16,  1912.  Her  gastric  pain  was  almost 
constant  and  very  severe  in  character,  and  she  vomited  almost 
daily.     In  this  case  also  at  the  secondary  (or,  rather,  the  tertiary) 


r 


4y/ 


■\ 


1 

a 

--- 

-4 

Fig.  90. — Gastro-enterostom}^  combined  with  jejunostomj^  (author's  method). 

operation  the  anastomosis  was  found  to  be  patent  and  a  jejunos- 
tomy  was  performed." 

The  operation  is  carried  out  as  follows : 

The  stomach  is  clamped  as  in  the  ordinary  operation ;  a  loop 
of  18  inches  of  jejunum  is  taken  and  an  anterior  vertical  anas- 
tomosis performed.  The  proximal  jejunal  loop  is  divided  near 
the  anastomosis,  and  implanted  into  the  portion  of  the  jejunum, 


254  ABDOMINAL    OPERATIONS. 

leaving  the  anastomosis,  the  distal  cut  end  near  the  anastomosis 
being  first  closed.  The  loop  of  jejunum  coming  from  the  duo- 
deno-jejunal  flexure  to  form  one  limb  of  the  Y  is  now  taken,  and 
at  a  point  two  or  three  inches  above  the  Y;  on  the  side  remote 
from  the  mesentery  a  small  longitudinal  incision  is  made  into  the 
lumen  of  the  gut,  and  a  No.  14  rubber  catheter  is  introduced. 
This  is  fixed  in  position  by  a  000,000  catgut  suture,  taking  all  the 
coats  of  the  bowel,  the  catheter  having  been  passed  down  the 
jejunum  4  or  5  inches  beyond  the  anastomosis.  Then  a  series 
of  interrupted  Pagenstecher  sutures  are  used,  as  in  Witzel's 
gastrostomy,  enclosing  the  catheter  in  a  trough  of  jejunum,  care 
being  taken  not  to  stenose  the  anastomosis.  The  line  of  suture 
is  then  fixed  to  the  abdominal  wall  by  a  single  stitch  at  each  end, 
and  the  wound  closed  snugly  round  the  catheter. 

THE  SURGICAL  TREATMENT  OF  ULCERATION  OF  THE  STOMACH  DUE 
TO  THE  DRINKING  OF  CAUSTIC  FLUIDS. 

x\n  examination  of  the  museum  specimens  and  a  search  into 
the  records  show  that  in  cases  in  which  an  intensely  irritating 
fluid  has  been  swallowed,  accidentally  or  with  suicidal  intent,  the 
parts  most  affected  are  lips  and  mouth,  the  pharynx,  and  the  first 
inch  or  more  of  the  oesophagus,  the  lower  end  of  the  oesophagus 
immediately  above  the  cardiac  orifice,  and  the  pylorus  and  py- 
loric antrum.  The  greater  part  of  the  oesophagus  escapes  serious 
damage,  though  patches  of  ulceration,  or  even  gangrene,  may 
be  distributed  throughout  it.  So  far  as  the  stomach  is  concerned, 
the  worst  injury  is  inflicted  on  the  pylorus,  but  in  severe  cases  the 
whole  mucous  membrane  may  be  affected. 

In  several  of  the  recorded  cases  appearances  very  closely  sim- 
ilar to  that  which  I  have  described  were  recognised.  The  con- 
traction and  consolidation  of  the  pyloric  portion  of  the  stomach 
have  been  frequently  observed.  Mr.  Keetley  likens  the  appear- 
ance in  one  of  his  cases  to  "a  small  sausage"  ;  of  a  second  he  says, 
"the  pylorus  was  thickened  and  so  contracted  that  it  woukl  only 
just  admit  the  closed  blades  of  a  pair  of  polypus  forceps";    and 


GASTRODUODENOSTOMY.  255 

a  third  that  there  was  "thickening  and  a  very  tight  stricture  of 
the  pylorus.  "  In  my  own  cases  the  pyloric  antrum  has  presented 
the  appearance  of  a  normal  uterus;  the  walls  are  thick  and  un- 
yielding, the  cavity  small,  and  the  pylorus  projects  downwards 
into  the  duodenum  like  the  cerv^ix  into  the  vagina. 

The  mucous  membrane  is  at  once  deeply  burned;  in  the 
stomach  it  assumes  very  rapidly  a  deep  purple  or  almost  black 
colour,  and  ulceration  speedily  follows.  In  many  of  the  speci- 
mens when  a  recent  examination  is  made  patches  of  gangrene 
with  adherent  food  particles  may  be  recognised.  In  addition  to 
the  cauterisation  due  to  the  irritating  fluid  a  septic  element  caused 
by  the  decomposition  of  adherent  food  particles  is  present. 

The  symptoms  noticed  at  the  first  moments  are  an  intense 
burning  of  the  labial  and  buccal  mucous  membranes,  a  scalding 
sensation  in  the  throat,  and  an  intense  burning  in  the  epigastriiim. 
In  many  cases,  though  not  in  the  one  now  recorded,  vomiting 
occurs.  The  agony  at  the  first  may  be  almost  unendurable,  and 
shock  is  profound. 

In  the  larger  number  of  cases  there  is  soon  a  marked  diffi- 
culty in  swallowing;  when  a  few  drops  only  of  fluid  are  swallowed, 
the  pain  elicited  may  be  excessive.  Thirst  is  intolerable,  the 
soreness  of  the  lips  and  mouth  when  the  sloughs  begin  to  separate 
is  terrible,  and  a  raw  bleeding  surface  may  be  left.  Vomiting  is  an 
early  and  a  constant  symptom ;  even  when  a  very-  small  quantity 
of  fluid  is  taken,  it  may  be  ejected  at  once  or  in  a  few  minutes. 

The  character  of  the  symptoms  changes  after  a  time,  accord- 
ing as  obstruction,  due  to  the  cicatricial  contraction  in  heaHng, 
is  caused  in  the  oesophagus  or  in  the  stomach.  When  a  stricture 
forms  in  the  gullet,  it  is  almost  always  at  the  upper  end;  when  in 
the  stomach,  it  is  at  the  pylorus  and  in  the  pyloric  antnmi.  In 
an  apparently  favourable  case  the  local  conditions  quickly  clear 
up,  and  fluid  food  may  be  taken  in  fair  quantity  and  retained,  but 
after  the  lapse  of  three  or  four  weeks  or  more  vomiting,  which  has 
been  absent  or  in  abeyance,  returns  more  seriously  than  before. 
The  stomach  dilates,  and  its  muscular  walls  hypertrophy  until 


256 


ABDOMINAL   OPERATIONS. 


the  usual  clinical  picture  of  pyloric  stenosis  is  produced  in  its 
most  exemplary  form. 

In  other  cases  the  characteristic  signs  of  obstruction  in  the 
oesophagus  are  produced,  and  in  still  others  there  may  be  obstruc- 
tion both  in  the  oesophagus,  at  the  upper  or  lower  end,  and  at  the 
pylorus. 

Treatment. — In  all  cases  it  is  of  the  first  importance  to  see 
that  there  is  complete  abstention  from  food  of  any  kind.     By 


I    ' 


Fig.  91. — Gastrostom}^  combined  with  gastro-enterostomy. 

giving  food  the  process  of  ulceration  is  quickened,  the  ulceration 
spreads,  gangrene  in  more  or  less  extensive  patches  occurs,  and 
a  virulent  septic  process  is  set  going.  The  chief  attempt  should 
be  directed  to  keeping  the  scalded  surfaces  sweet  and  clean. 
Mouth- washes,  sprays,  gargles,  frequent  mopping  of  the  ulcers 
with  gauze  swabs,  all  are  useful  in  helping  to  ensure  cleanliness. 
The  administration  of  saline  enemata  by  the  rectum  will  help  to 
relieve  thirst  to  some  extent. 


GASTRODUODENOSTOMY.  257 

It  is  probable  that  in  all  cases  the  safest  course  will  be  to  have 
an  early  resort  to  surgery.  By  means  of  some  operative  pro- 
cedure the  feeding  of  the  patient  can  be  ensured  for  such  a  time 
as  will  allow  healing  to  take  place  in  the  ulcerated  patches. 

The  two  operations — one  of  which  will  usually  be  needed — 
are  gastrostomy,  when  the  oesophagus  alone  is  affected,  and  gas- 
tro-jejunostomy  combined  with  gastrostomy,  when  the  pyloric 
portion  of  the  stomach  is  most  injured.  Duodenostomy,  as  prac- 
tised by  Hartmann,  or  jejunostomy  alone,  suffices  merely  to  feed 
the  patient  for  a  time.  They  do  nothing  towards  securing  him 
against  the  almost  certain  troubles  which  will  result  from  the 
mechanical  obstruction  at  the  pylorus  due  to  the  healing  of  the 
deeply  ulcerated  mucosa. 


■17 


CHAPTER  XIV. 

EXCISION  OF  GASTRIC  ULCER. 

In  the  early  days  of  the  surgical  treatment  of  gastric  dis- 
orders the  surprising  results  obtained  after  gastro-enterostomy 
had  been  performed  in  cases  of  pyloric  obstruction  gave  a  very 
exalted  reputation  to  this  procedure.  The  drainage  of  the  stom- 
ach, which  in  such  cases  was  the  chief  necessity,  was  believed  to  be 
the  need  also  in  cases  of  ulcer  found  in  parts  of  the  organ  distant 
from  its  outlet.  Because  the  cases  dealt  with  in  the  days  of  pio- 
neer work  embraced  chiefly  those  in  which  a  stenosis  was  present, 
and  because  a  short-circuiting  operation  endowed  the  patients  sub- 
mitted to  it  with  the  most  robust  health,  it  was  illogically  assumed 
that  gastro-enterostomy  was  the  operation  called  for  in  all  cases 
of  gastric  ulceration.  A  series  of  patients  at  the  hands  of  many 
operators  were  accordingly  treated  by  the  operation  of  gastro- 
enterostomy when  either  no  ulcer  at  all  was  discoverable  in  the 
stomach  (a  lesion  probably  existing  elsewhere)  or  when  a  very 
little  ulcer,  seen  or  felt,  lay  at  some  point  along  the  lesser  curva- 
ture, perhaps  nearer  the  cardia  than  the  pylorus,  or  upon  the  an- 
terior or  posterior  surface.  The  immediate  results  of  the  treat- 
ment of  such  chronic  ulcers  were  often  satisfactory,  but  a  scrutiny 
of  the  after-results  in  my  own  cases  demonstrated  that  in  a  large 
proportion  the  ultimate  condition  of  the  patient  was  far  from 
good.  I  found  that  I  was  able  to  classify  each  case  into  three 
groups.  In  the  first,  a  small  group,  embracing  roughly  30  per 
cent,  of  the  total  number,  the  patients,  after  a  period,  generally 
of  many  months,  regained  their  health  and  appetite,  lost  all  the 
discomforts  of  dyspepsia,  and  with  care  were  able  to  eat  well  and 
enjoy  life.  They  were  indeed  fit  to  be  pronounced  "cured," 
though  perhaps  all  did  not  display  that  sturdy  and  even  reckless 
confidence  in  their  capacities  which  the  patient  who  has  been  re- 

258 


EXCISION    OF   GASTRIC    ULCER.  259 

lieved  of  an  obstructive  lesion  so  constantly  possesses.  In  the 
second  group  the  patients  soon  began  to  make  complaint  of  a  re- 
turn of  their  former  gastric  derangements,  and  in  the  end  willingly- 
submitted  to  a  second  operation,  in  which  an  excision  of  the  ulcer 
or  a  pylorectomy  had  to  be  performed.  In  the  third  group,  after 
a  period  of  variable  health,  the  symptoms  returned  as  severely  as 
ever,  weight  was  lost,  cachexia  developed,  and  the  patients  died 
of  carcinoma  of  the  stomach.  It  might  be  urged  of  these  that  a 
mistake  in  the  diagnosis  had  been  made  at  the  time  of  operation, 
and  the  possibility  of  such  an  error  must  be  conceded:  but  in 
many,  indeed  in  most,  the  time  which  had  elapsed  from  the  oper- 
ation to  the  death  of  the  patient,  two  and  one-half,  three,  or  even 
five  years,  made  it  seem  more  probable  that  the  carcinoma  had 
developed  upon  the  base  of  an  old  ulcer.  A  comparison  was  made 
between  the  indubitable  cases  of  gastric  carcinoma  treated  by 
gastro-enterostomy  and  these  cases;  in  the  former  group  it  was 
rare  for  a  patient's  life  to  be  prolonged  by  a  year  and  a  half  or 
more;  in  the  latter  life  w^as  advanced  two  and  one-half  years  or 
more.  Even  allowing  for  the  possibility  of  an  occasional  mistake, 
there  could,  we  thought,  be  no  doubt  that  in  a  large  number  of 
cases  pathological  processes,  at  first  simple,  had  at  last  become 
malignant. 

The  question  therefore  arose  as  to  whether  the  operation  of 
gastro-jejunostomy  should  not  be  abandoned  in  all  cases  where 
the  ulcer  lay  at  a  little  distance  from  the  pylorus,  and  be  replaced 
by  an  excision  of  the  ulcer  with  restitution  of  the  integrity  of  the 
stomach  where  this  was  possible ;  or  by  the  performance  of  Rod- 
man's operation  when  the  ulcer  was  contiguous  to  the  pylorus, 
and  when  there  was  an  inveterate  and  indurated  ulcer  likely  to 
become  malignant. 

This  then  became  our  plan  of  procedure.  If  an  ulcer  lay  in 
the  pyloric  region,  either  in  the  duodenum  (far  more  frequently) 
or  in  the  stomach  (rarely),  and  was  causing  stenosis  and  was 
clearly  not  malignant,  gastro-enterostomy  was  performed.     If  a 


260  ABDOMINAL  OPERATIONS. 

single  ulcer  la}^  in  the  body  of  the  stomach  and.  was  not  causing 
an  hour-glass  deformity,  it  was  excised. 

If  an  ulcer  near  the  pylorus  was  very  thick,  much  indurated, 
and  possibly  malignant,  or  if  ulcers  were  multiple,  Rodman's 
operation  was  considered  to  be  necessary. 

When  the  excision  of  the  ulcer,  say  on  the  lesser  curvature, 
two  or  three  inches  away  from  the  pylorus,  was  performed,  we 
found,  at  times,  that  an  unsightly  deformity  of  the  stomach  re- 
sulted, and  in  a  few  cases  a  second  operation  became  necessary, 
either  because  the  ulcer  had  recurred,  or  because  the  healing  of 
the  suture  line  and  perhaps  also  its  adhesion  to  parts  adjacent, 
had  caused  a  difficulty  in  the  proper  working  of  the  stomach  which 
only  a  short-circuiting  operation  could  relieve.  In  such  cases, 
therefore,  we  began  to  combine  gastro-enterostomy  with  excision, 
the  new  anastomosis  being  made  a  little  proximal  to  the  new 
suture  line.  In  three  cases  of  my  own  ulcers  on  the  lesser  curva- 
ture, treated  by  excision,  recurred,  so  far  as  we  could  judge, 
exactly  in  the  suture  line,  and  in  two,  perforation  of  the  ulcers 
necessitated  urgent  secondary  operations.  Such  recurrences  may 
be  due  to  the  inadequate  removal  of  the  original  ulcer.  The  in- 
duration and  thickening  around  the  crater  of  an  ulcer  extend 
sometimes  very  widely,  and  if  the  size  of  the  crater  is  taken  as 
the  measure  for  the  area  to  be  excised,  diseased  tissue  may  be 
left  behind.  The  hard  fibrous  edge  of  the  wound  so  made  may 
heal  unkindly,  and  a  new  ulcer  develope  exactly  in  the  line  of 
suture.  I  have,  therefore,  made  it  a  rule  for  the  last  few  years  to 
excise  an  ulcer  very  widely,  cutting  all  round  the  crater,  in  tis- 
sues which  are  soft  and  healthy.  So  free  a  removal  of  the  parts, 
however,  has  the  disadvantage  that  a  deformity  of  the  stomach  is 
far  more  likely  to  result  when  the  suturing  is  completed.  Since 
we  have  combined  gastro-enterostomy  with  excision  this  has  not, 
however,  been  a  serious  disadvantage,  and  it  has  had  the  supreme 
merit,  so  far,  of  preventing  recurrences. 

The  experience  which  I  have  had  with  regard  to  ulcers  of  the 
body  of  the  stomach,  and  the  inefficacy  of  gastro-enterostomy  in 


EXCISION    OF   GASTRIC    ULCER.  26 1 

curing  them,  is  that  which  I  beheve  has  been  the  lot  of  most 
other  surgeons.  There  are  two  notable  exceptions.  Kocher, 
to  whose  opinion  the  greatest  weight  always  attaches,  is  satisfied 
that  in  his  hands  gastro-enterostomy  will  cure  a  gastric  ulcer, 
wherever  the  ulcer  may  be. 

H.  Paterson  (''Surgery  of  the  Stomach,"  pp.  86-94)  ^^so  con- 
siders that  even  if  the  ulcer  lie  near  the  cardia,  or  at  any  part  of 
the  body  of  the  stomach,  the  anastomosis  of  the  stomach  with  the 
jejunum  will  allow  or  even  encourage  the  ulcer  to  heal.  These 
writers  believe  in  the  "physiological  effect"  of  a  gastro-enter- 
ostomy as  something  different  from  its  merely  mechanical  effect. 
Paterson  asserts  that  the  entry  of  the  intestinal  contents,  bile, 
and  pancreatic  juice  into  the  stomach,  neutralising  the  acidity  of 
the  gastric  juice,  has  a  very  decided  effect  in  allowing  an  ulcer  to 
heal. 

The  work  of  Barclay  and  others,  who  have  examined  the  stom- 
ach by  means  of  :r-rays  after  bismuth  meals  had  been  admin- 
istered, may  throw  some  light  on  the  discrepancies  which  exist 
between  the  surgeons  upon  this  subject.  Barclay  has  shewn 
("The  Stomach  and  GEsophagus,"  London,  1913)  that  in  all 
cases  of  gastric  ulcer  a  spasm  of  the  stomach  may  appear,  at  times 
in  the  body  of  the  organ  at  the  area  of  ulceration,  producing  an 
hour-glass  shape  in  the  stomach,  at  times  in  the  pyloric  end  only, 
but  in  both  cases  causing  definite  obstruction.  It  may  be  that 
the  cases  of  gastric  ulcer  cured  by  gastro-enterostomy  are  made 
up  largely  or  solely  of  those  in  which  an  obstructive  spasm  was 
present;  the  short-circuiting  operation,  acting  then  purely  as  a 
mechanical  relief  to  the  ulcer,  by  allowing  food  to  escape  from 
contact  with  it  more  quickly  than  in  ordinary  circumstances. 
My  own  experience,  however,  is  very  much  opposed  to  the  per- 
formance of  gastro-enterostomy  alone  in  any  case  of  ulcer  on  a 
level  with  or  proximal  to  the  site  of  the  anastomosis. 

In  connexion  Vv^ith  the  surgical  treatment  of  ulcers  of  the  stom- 
ach, the  following  general  propositions  may  be  affirmed : 

I.  In  cases  of  obstruction  at,  or  near,  the  pylorus  the  result 


262  ABDOMINAL   OPERATIONS. 

of  the  scar  of  former  ulcers,  the  operation  of  gastro-enterostomy 
will  afford  complete  and  permanent  relief. 

2.  Ulcers  lying  in  parts  of  the  stomach  other  than  the  pyloric 
antrum  are  best  treated  by  excision.  Gastro-enterostomy 
causes  rehef ,  or  cure  in  some,  but  in  others  the  result  is  bad  or  in- 
different. 

3.  An  ulcer  lying  upon  the  lesser  curvature  if  of  small  size 
can  be  excised  without  the  resulting  scar  causing  any  deformity 
of  the  stomach ;  if  of  large  size  excision  should  be  combined  with 
gastro-enterostomy.  These  cases  are  sometimes  exceedingly 
difficult. 

4.  An  ulcer  lying  upon  the  posterior  surface  of  the  stomach 
may  be  reached  through  the  gastro-hepatic  omentum,  or  through 
the  transverse  mesocolon,  or  by  incision  through  the  anterior  wall 
of  the  stomach. 

5.  Large  ulcers  occupying  a  considerable  extent  of  the  lesser 
curvature,  excavating  perhaps  the  liver  or  the  pancreas  cannot 
be  treated  by  excision  as  this  would  involve  complete  gastrec- 
tomy. I  have  found  that  gastro-enterostomy  combined  with 
jejunostomy  gives  the  best  results. 

6.  In  cases  of  ulcer  lying  near  the  pylorus,  where  induration 
is  considerable,  the  ulcer  being  of  the  "callous"  variety,  or  when 
ulcers  in  the  pyloric  region  are  multiple,  the  excision  of  the  "ulcer- 
bearing"  area  of  the  stomach — Rodman's  operation — is  the 
method  of  choice. 

TECHNICAL  CONSIDERATIONS. 

I .  If  an  ulcer  of  small  size  should  be  discovered  in  the  body  of 
the  stomach  on  the  anterior  wall,  and  be  free  from  marked  in- 
duration or  adhesion  to  other  parts,  it  may  easily  be  removed. 
Two  incisions  lying  approximately  parallel  to  the  curvatures  of 
the  stomach  should  be  made  to  surround  the  ulcer,  and  should  fall 
entirely  upon  healthy  parts ;  this  is  essential.  The  incision  which 
remains  after  the  ulcer  is  removed  is  then  stitched  up  so  that  the 
line  of  suture  runs  from  one  curvature  to  the  other;  it  lies,  that  is 


EXCISION   OF   GASTRIC    ULCER.  263 

to  say  at  right  angles  to  the  hnes  along  which  the  original  incisions 
were  made.  In  this  way  it  will  be  made  certain  that  no  narrow- 
ing in  the  calibre  of  the  stomach  occurs  when  healing  is  com- 
plete. The  sutures  are  placed  in  two  layers,  an  inner  of  catgut 
and  an  outer  of  Pagenstecher  thread.  Generally  it  is  better  to 
make  the  catgut  suture  of  the  interrupted  form.  The  outer 
thread  is  best  introduced  by  Cushing's  right-angled  method;  it 
is  therefore  continuous.  The  perfectly  smooth  appearance  of 
the  suture  line,  with  no  thread  shewing,  which  results  when  this 
stitch  is  used  is  the  surest  method  of  preventing  adhesion  between 
the  stomach  and  the  abdominal  wall. 

2.  If  the  ulcer  should  lie  along  the  lesser  curvature  of  the 
stomach,  sending  a  branch  down  on  to  the  anterior  or  the 
posterior  surface  or  on  to  both  surfaces  of  the  stomach,  resection 
may  be  difficult  owing  to  the  adhesion  of  the  ulcer  to  the  liver 
or  the  pancreas,  or  because  of  the  remoteness  of  the  ulcer  from 
the  abdominal  incision.  As  a  rule,  however,  the  involved  parts 
of  the  stomach  can  be  draw^n  up  into  the  w^ound  without  too 
great  traction  being  employed,  and  without  any  addition  being 
necessary  to  the  original  parietal  incision.  When  the  stomach 
has  been  coaxed  up  into  the  wound  the  abdominal  cavity  is 
securely  packed  off  with  hot  moist  swabs  which  are  placed  care- 
fully in  all  directions.  The  lesser  sac  may  be  guarded  by  swabs 
introduced  either  through  the  gastro-hepatic  omentum,  or 
through  an  incision  in  the  transverse  mesocolon  made  after  the 
colon  has  been  raised.  When  all  gauze  packing  is  in  place 
mackintosh  sheets  are  put  over  them,  and  over  the  abdominal 
wall,  so  as  to  keep  all  parts  not  immediately  engaged  in  the 
operation  free  from  the  risk  of  infection. 

The  purpose  of  the  operation  is  to  remove  a  wedge  from  each 
surface  of  the  stomach,  the  base  being  at  the  lesser  curvature,  and 
the  apex  pointing  towards  the  greater  curvature.  The  operation 
may  be  begun  by  the  ligature  of  the  coronary  artery  at  each  end . 
of  the  base  of  the  wedge  to  be  removed ;  but  I  have  often  found 
it  possible  to  dissect  off  the  artery  from  the  lesser  curvature. 


264 


ABDOMINAL   OPERATIONS. 


lifting  it  away  during  the  time  the  ulcer  is  resected,  and  replacing 
it  at  the  end  of  the  operation.  When  the  vessel  is  secured  in  one 
or  other  of  these  ways  a  clamp  is  introduced  between  the  ulcer 
and  the  cardia,  and  another  between  the  pylorus  and  the  ulcer, 
so  that  the  whole  territory  to  be  dealt  with  is  embraced  by  the 
clamps,  which  render  the  parts  avascular  and  prevent  soiling  of 
the  field  by  the  escape  of  gastric  contents.     The  ulcer  is  then  ex- 


Fig.  92. — Excision  of  an  ulcer  on  or  near  the  lesser  curvature  of  the  stomach. 
The  clamps  are  applied  to  include  the  ulcer  which  is  excised  after  separation 
of  the  gastro-hepatic  omentum.      In  the  small  figure  the  first  stitch  is  shewn. 


cised,  the  incisions  being  carried  well  into  sound  tissues.     The 
gaping  of  the  wound  is  often  very  wide  when  this  is  done. 

The  appearance  seen  in  the  figure  is  then  presented.  There 
is  a  long  wound  through  all  the  coats  of  the  stomach  beginning 
on  the  posterior  surface,  mounting  over  the  lesser  curvature  and 
ending  on  the  anterior  surface.  The  closure  of  this  wound  be- 
gins on  the  lowest  point  of  the  posterior  surface  and  continues 


EXCISION    OF   GASTRIC   ULCER. 


265 


round  to  the  lowest  point  on  the  anterior  wall.  The  suture  is  a 
through-and-through  suture  of  catgut,  and  it  is  of  the  Connell 
type.  The  needle  passes  on  each  side  from  serous  to  mucous  and 
from  mucous  to  serous  surface,  then  crosses  the  gap,  and  passes 
again  on  the  opposite  cut  margin  from  serous  to  mucous  surface 
and  back  from  mucous  to  serous.  The  diagram  shews  how  this 
stitch  is  passed.     On  each  side  a  "loop  on  the  mucosa"  is  left. 


Fig.   93. — The  suture  continued — note  that  the  stitch  is  of  the  "loop  on  the 

mucosa"  type. 

By  the  time  the  lowest  part  of  the  anterior  surface  is  reached  a 
single  Lembert  stitch  is  taken  to  complete  the  line.  The  clamps 
are  then  removed,  and  sometimes  a  bleeding  point  or  two  may  ap- 
pear and  require  to  be  secured.  An  outer  layer  of  suture  is  now 
necessary.  The  difficulty  of  its  introduction  may  be  consider- 
able. The  posterior  surface  of  the  stomach  may  be  turned  up- 
wards through  the  gap  in  the  lesser  omentum,  or  it  may  be  reached 
through  the  incision  already  made  in  the  transverse  mesocolon. 


266 


ABDOMINAL   OPERATIONS. 


I  have  often  borrowed  a  flap  from  the  transverse  mesocolon  to 
place  over  the  posterior  suture  line  to  prevent  a  new  adhesion  to 
the  pancreas.  The  anterior  line  is  then  reinforced  by  a  suture  of 
the  right  angled  Gushing  type. 

Instead  of  the  Connell  suture,  which  is  of  course  continuous, 
interrupted  through-and-through  Lembert  sutures  or  the  Hal- 
sted  suture  may  be  used.  I  have  tried  them  all  and  do  not  find 
any  difference  between  them.  The  essential  thing  is,  I  believe, 
to  prevent  the  suture  line  contracting  adhesions,  either  to  the  pan- 


Fig.  94. —  The  sutures  completed. 


creas  behind  or  to  the  abdominal  wall  in  front,  for  the  fixity  w^hich 
thereby  results  is  I  feel  sure  a  powerful  factor  for  harm  (see  Coffey, 
"Surg.,  G}^.,  andObst.,"  1910,  ii,  545). 

3.  If  the  ulcer  involves  too  large  an  extent  of  the  surfaces 
of  the  stomach,  as  well  as  of  the  lesser  curvature,  or  if  a  large 
ulcer  be  present  on  either  anterior  or  posterior  surface,  then  the 
whole  segment  of  the  stomach  in  which  the  ulcer  lies  may  be  ex- 
cised. A  cylindrical  portion  of  the  organ,  that  is  to  say,  is  re- 
moved together  with  the  ulcer.     This  operation  may  be  called 


EXCISION   OF   GASTRIC    ULCER. 


267 


annular  gastrectomy.  The  operation  is  performed  in  the  follow- 
ing manner.  The  two  curvatures  of  the  stomach  are  freed  from 
the  omenta  as  widely  as  necessary,  by  ligature  of  the  coronary 
and  gastric  epiploic  vessels  above  and  below.  A  cylinder  of  the 
stomach  is  in  this  way  denuded  of  its  blood-supply.  At  each  end 
of  this  cylinder  two  pairs  of  clamps  are  placed  and  between  each 


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111 

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Fig.  95. — Excision  of  an  ulcer  in  the  body  of  the  stomach.  The  omenta 
have  been  ligatured.  The  dotted  lines  shew  how  section  of  the  stomach  is  to 
be  made. 


pair  the  stomach  is  divided.  The  diseased  ring  of  the  stomach  is 
then  removed.  The  clamps  which  close  the  cut  ends  of  the  parts 
of  the  stomach  which  remain  are  brought  together  for  anastomosis 
with  one  another.  The  surgeon  must  have  foreseen  the  need  for 
making  these  divided  ends  of  approximately  the  same  size.     This 


268 


ABDOMINAL   OPERATIONS. 


may  easily  be  done  by  placing  the  distal  clamp  a  little  obliquely, 
so  that  a  longer  section  of  the  stomach  from  curvature  to  curva- 
ture is  made.  There  is  usually  no  difficulty  in  bringing  the  cut 
ends  of  the  stomach  into  easy  apposition,  for  an  ulcer  which  in- 
volves so  large  an  extent  of  surface  as  to  call  for  partial  gastrec- 


f  ff'-i*4 


Fig.   96. — Excision  of  an  ulcer  in  the  body  of  the  stomach.     The  outer 
suture  completed  in  its  first  half;   the  inner  suture  being  applied. 

tomy  has  probably  caused  some  obstruction  and  dilatation  and 
a  degree  of  hypertrophy  in  consequence. 

When  the  clamps  are  placed  side  by  side  the  anastomosis 
is  carried  out  exactly  as  if  gastro-enterostomy,  or  the  ordinary 
gastro-anastomosis  were  to  be  made.  Two  continuous  sutures 
are  used;  an  outer  serous,  and  an  inner  which  secures  all  the 
coats,  and  so  acts  as  an  haemostatic.     The  anterior  half  of  the 


EXCISION   OF    GASTRIC    ULCER. 


269 


outer  suture  is  best  introduced  by  the  right-angled  Gushing 
method,  for  the  reason  already  given,  that  it  leaves  a  smoother 
surface,  one  less  likely  to  adhere  to  the  parietal  peritoneum. 

4.  If  the  ulcer  lies  on  the  posterior  surface,  perhaps  adherent 
to  the  pancreas,  it  may  be  removed  by  one  of  three  methods: 

(a)  By  rotation  of  the  stomach  to  a  degree  which  allows  the 
posterior  surface  together  with  the  ulcer  to  be  pushed  forward 


Fig.  97. — Transgastric  resection  of  ulcer  in  posterior  surface,  showing  line 
of  incision  surrounding  the  talcer. 

through  an  aperture  in  the  gastro-hepatic  omentum.  A  few 
stay-sutures  passed  into  the  stomach  a  little  distance  away  from 
the  ulcer  will  hold  the  parts  well  up  to  the  parietal  wound  while 
excision  is  being  made.  This  method  is  advocated  by  J.  E.  Sum- 
mers ("Jour.  Amer.  Med.  Assoc,"  1911,  Ivi,  1699)  to  whom  we 
are  indebted  for  many  valuable  technical  suggestions  in  abdom- 
inal surgery. 


270 


ABDOMINAL   OPEIL\TIONS. 


(b)  By  approaching  the  stomach  through  the  transverse 
mesocolon,  as  in  the  operation  of  posterior  gastro-enterostomy. 
The  hinder  surface  of  the  stomach  is  drawn  well  upwards  and  the 
ulcer,  if  small,  is  easily  excised.  A  flap  of  the  transverse  meso- 
colon is  then  borrowed  for  application  to  the  posterior  wall  of 
the  stomach  after  the  suture  is  completed. 


Fig.  98. — Transgastric  resection  of  ulcer  on  posterior  surface. 


(c)  By  the  transgastric  method  (see  Chaput,  "Bull,  et  Mem. 
Soc.  de  Chir.,"  1894,  P-  45^;  Brenner,  "Wien  klin.  Woch.," 
1896,  p.  117;  Pilcher,  "Long  Island.  Med.  Jour.,"  May,  1908, 
p.  187;  W.  J.  Mayo,  "Ann.  Surgery,"  1910,  ii,  797,  and  Coffey, 
"Surg.,  Gyn.  and  Obst.,"  1910,  ii,  545).  The  ulcer  is  first  freed 
from  any  adhesion  it  may  have  contracted  to  the  pancreas.  In 
doing  this  it  is  not  infrequent  to  find  that  the  stomach  is  opened 
at  the  base  of  the  ulcer.     A  subacute  perforation  has    occurred 


EXCISION    OF    GASTRIC    ULCER. 


271 


long  ago  and  the  pancreas  has  actually  formed  a  part  of  the  base 
of  the  thick-walled  ulcer.  During  the  stage  of  separation,  and 
afterwards,  great  care  is  taken  to  protect  the  lesser  sac  by  packing 
gauze  swabs  through  apertures  made  in  the  gastro-hepatic  omen- 
tum, and  in  the  transverse  mesocolon.  These  gauze  swabs  gen- 
erally suffice  by  their  pressure  to  arrest  any  bleeding  that  may 
occur  from  the  denuded  surface  of  the  pancreas.     When  the  ulcer 


Fig.  99. — Transgastric  resection  of  ulcer  on  posterior  surface. 


is  quite  freed  and  the  stomach  can  be  brought  well  up  into  the 
wound  an  incision  about  3  to  5  inches  in  length  is  made  through 
the  anterior  wall  of  the  stomach  opposite  to  the  ulcer;  the  in- 
cision runs  parallel  to  the  long  axis  of  the  stomach.  A  few  vessels 
may  bleed  freely;  they  are  seized  with  small  clips,  and  the 
stomach-contents,  if  necessary,  mopped  away.  The  finger  of 
the  surgeon  or  an  assistant  passed  up  through  the  opening  in  the 


272 


ABDOMINAL  OPERATIONS. 


transverse  mesocolon  presses  forward  the  posterior  wall  of  the 
stomach  and  cause  it  to  protrude  between  the  margins  of  the 
wound  in  the  anterior  surface.  This  movement  is  enough  also 
to  prevent  any  escape  of  the  sparse  contents  that  may  be  present 
in  the  stomach.  Coffey  advises  the  introduction,  around  the 
wound,  of  stay  sutures,  traction  upon  which  will  prevent  the  es- 
cape of  fluids  from  the  stomach.  The  ulcer  is  now  surrounded  by 
an  incision,  roughly  elliptical  in  form,  which  cuts  well  into  healthy 
tissue  at  every  part. 


Fig.    100. — Placing   traction   loops   preparatory  to   opening   the    stomach    for 

exploration  (Coffey). 


The  wound  in  the  posterior  wall  which  now  remains  may  be 
closed  by  a  single  layer  of  through-and-through  sutures  intro- 
duced from  the  mucous  surface.  It  is  necessary  that  the  suture 
should  be  of  thread  since  one  has  to  rely  upon  a  single  layer.  I 
have  generally  used  an  interrupted  series  of  sutures  placed  closely 
together,  but  a  continuous  suture,  which  I  have  also  used,  is  per- 
haps equally  satisfactor}^  The  sutures  have  to  be  discharged 
into  the  stomach  and  to  escape;  and  it  is  perhaps  easier  for  a 
short  interrupted  suture  to  do  this  than  for  a  long  continuous  one. 


EXCISION    OF    GASTRIC    ULCER. 


273 


Fig.  10 1. — ^^The  stomach  has  been  incised,  exposing  the  mucous  surface.  A 
callous  ulcer  is  seen  in  the  background,  while  the  fluid  contained  in  the  stomach 
may  be  seen  gravitating  to  the  back.  Dotted  line  indicates  extent  of  incision 
by  which  this  ulcer  was  removed  from  the  posterior  wall  and  the  lesser  curva- 
ture (Coffey). 


Fig.  102. — First  step  in  closing  an  incision  in  the  stomach  wall.  Beginning 
knot  of  through-and-through  right-angle  suture  is  being  tied  from  the  inside 
(Coffey). 


274 


ABDOMINAL   OPERATIONS. 


As  a  rule,  complete  confidence  may  be  felt  in  the  security  of 
the  suture  line,  but  if  a  further  auxiliary  stitch  is  thought  neces- 
sar^^  it  may  be  that  the  hinder  wall  of  the  stomach  can  be  brought 
out  through  the  transverse  mesocolon,  as  in  von  Hacker's  opera- 
tion, and  an  additional  stitch  or  two  introduced.  If  it  is  thought 
necessary,  a  small  wick  of  dental  rubber  may  be  left  in  the  lesser 
sac  to  act  as  a  drain.  I  do  not  favour  this,  and  have  never  em- 
ployed any  drainage  in  any  of  my  cases.  It  is  quite  enough  to 
ensure  safety  if  scrupulous  care  is  taken  to  avoid  soiling  of  the 


f 

WWk 

^^^^^^-Vft^j^^iN 

ii 

—        ^- 

M^  tfc^aii&.:S^^JijMi» 

^ 

l^w^ 

li- 

{ 

\tj 

) 

-** 

K, 

^ 
^ 

Fig.  103. — Continuing  through-and-through  right -angle  suture  and  tying  oppos- 
ing loops  over  it  (Coffey). 


parts  by  escaping  fluids.  The  use  of  the  mackintosh  sheets 
makes  this  a  simple  problem.  If  the  suture  line  is  well  completed 
drainage  is  then  quite  unnecessary" :  if  the  suture  line  is  not  com- 
petent to  hold,  no  drainage  will  save  the  patient.  Indeed  the 
use  of  even  a  thin  soft  rubber  drain  is  probabty  harmful.  I  have 
used  the  transgastric  method  for  the  resection  of  a  jejunal  ulcer, 
in  one  case,  with  great  satisfaction. 

After  all  these  forms  of  excision  of  gastric  ulcer  I  am  rather 
chary  about  giving  food  for  three  or  four  days.     I  do  not  encour- 


EXCISION    OF    GASTRIC    ULCER.  275 

age  the  patients  to  drink  more  than  they  need  to  slake  their 
thirst.  Continuous  sahne  injections  by  the  rectum  will  easily 
supply  all  fluids  necessary  for  the  first  few  days.  Drinks  are 
given  chiefly  for  the  gratification  of  the  patients, 

(d)  In  one  case  of  large  ulcer  adherent  to  the  pancreas  Lynn 
Thomas  pared  the  margins  of  the  ulcer  and  dissected  the  mucous 
membrane  up  until  he  was  able  to  bring  the  edges  together  over 
the  base  of  the  ulcer  where  they  were  sutured.  The  patient,  a 
domestic  servant  in  his  own  employment,  remains  well  after  sev- 
eral years.  The  same  procedure  has  been  adopted  by  Phillips  of 
Bradford  in  two  cases  with  excellent  results. 


CHAPTER   XIV. 
OPERATIONS  FOR  HOUR-GLASS  STOMACH. 

Ax  hour-glass  stomach  may  be  congenital  or  acquired- 
Congenital  hour-glass  stomach,  the  existence  of  which  I  have 
formerly  disputed,  is  extremely  rare.  Only  one  undoubted 
case  has  been  reported.  Acquired  hour-glass  stomach  may  be 
due  to  the  contraction  of  a  chronic  ulcer  situated  in  the  body  of 
the  organ,  to  cancer,  to  localised  perforation  of  an  ulcer  in  the 
body  of  the  stomach  followed  by  adhesion  and  anchoring  of  the 
stomach  to  the  anterior  abdominal  wall  or  to  the  pancreas,  and, 
finally,  to  perigastric  adhesions  which  compress  the  stomach 
at  or  near  its  centre.  In  one  remarkable  case  upon  which  I 
operated  two  constrictions  were  present,  so  that  a  triloculated 
stomach  was  formed. 

The  stricture  which  divides  the  stomach  into  two  portions 
may  be  placed  at  any  point  between  the  cardiac  and  pyloric 
orifices.  As  a  rule,  it  is  nearer  to  the  pylorus  than  to  the  cardia, 
and  as  a  result  of  the  obstruction  which  it  causes  the  cardiac 
pouch  undergoes  a  marked  dilatation.  In  the  great  majority 
of  cases  the  greater  curvature  is  pulled  upwards  to  the  lesser, 
but  in  two  cases  I  have  seen  the  normal  outline  of  the  greater 
curA^ature  has  been  unaltered,  the  lesser  curvature  being  tucked 
down  towards  it. 

Hour-glass  stomach  is  very  much  more  common  than  was 
formerly  believed.  I  have  operated  upon  54  well-marked  ex- 
amples. The  condition,  I  believe,  is  occasionally  overlooked, 
owing  to  an  imperfect  examination  of  the  stomach.  When,  as 
not  seldom  happens,  there  is  an  obstruction  at  the  pylorus  as 
well  as  in  the  body  of  the  stomach,  the  food,  after  passing  from 
the  cardiac  into  the  pyloric  pouch,  again  meets  with  an  obstruc- 
tion, and  finds  great  difficulty  in  escaping  through  the  narrowed 

276 


OPERATIONS   FOR  HOUR-GLASS    STOMACH. 


277 


pylorus  into  the  duodenum.  The  pyloric  pouch  then  becomes 
gradually  dilated  and  hypertrophied.  It  may,  indeed,  be  so 
large  that  when  the  abdomen  is  opened  it  is  mistaken  for  the 
whole  stomach  and  a  gastro-enterostomy  is  performed  between 
it  and  the  jejunum.     Such  an  operation  is,  of  course,  doomed 


Fig.  104. — Types  of  hour-glass  stomach:  i,  Obstruction  near  cardiac  end; 
2,  cardiac  pouch  concealed  by  adhesions;  3,  growth  in  body  of  stomach;  4, 
two  pouches  connected  by  a  narrow  tube;  5,  cardiac  pouch  largely  dilated; 
6,  lesser  curvature  pulled  down  towards  the  greater. 


to  complete  failure;  for  the  symptoms  are  mainly  due  to  the 
stenosis  between  the  cardiac  and  the  pyloric  pouch,  which  is 
unrelieved.  The  most  necessary  precept  to  bear  in  mind  in 
operating  upon  the  stomach  is  that  the  whole  stomach,  from 
cardia  to  pylorus,  should  be  seen  and  felt  before  any  anastomo- 
sis is  made.     In  at  least  three  recorded  cases  a  lack  of  ade- 


278  ABDOMINAL   OPER.\TIONS, 

quate  and  precise  knowledge  of  the  condition  of  the  stomach 
has  led  to  futile  measures  and  fatal  results. 

In  many  cases  of  hour-glass  stomach,  as  I  have  said,  there 
is,  in  addition  to  the  constriction  in  the  middle  of  the  organ,  a 
narrowing  due  to  old  ulceration  at  the  pylorus.  It  is  because  of 
this  dual  stenosis  that  the  treatment  b}^  operation  is  often  a 
matter  of  difficulty.  In  such  circumstances  no  single  operation 
will  suffice  to  cure  the  patient ;  for  if  gastro-enterostomy  is  per- 
formed between  the  cardiac  complement  and  the  jejunum,  food 
will  escape  through  the  isthmus  into  the  pyloric  pouch,  and,  there 
stagnating,  will  undergo  decomposition  and  cause  distension, 
flatulence,  pain,  and  the  occasional  vomiting  of  putrid  fluids. 
If  the  anastomosis  is  made  between  the  pyloric  pouch  and  the 
jejunum,  the  symptoms  which  the  operation  was  destined  to 
relieve  will  persist.  In  these  cases,  therefore,  a  double  opera- 
tion must  be  performed ;  a  free  passage  must  be  made  from  the 
cardiac  pouch  to  the  pyloric,  and  thence  to  the  jejunum.  The 
following  operations  may  be  performed: 

1.  Gastro-enterostom}^  single  or  double. 

2.  Gastroplasty. 

3.  Gastrogastrostom.}^  or  gastro-anastomosis. 

4.  Partial  gastrectomy^ 

5.  Dilatation  of  the  constriction. 

I.  Gastro-enterostomy  alone  is  suitable  for  a  certain  number 
of  cases.  When  the  constriction  is  within  two  or  three  inches 
of  the  pylorus,  the  pyloric  pouch  is  small,  not  dilated,  and,  from 
the  surgical  point  of  view,  is  negligible.  Nothing  more  is  neces- 
sary to  effect  a  cure  than  a  free  outlet  from  the  cardiac  pouch, 
and  this  is  afforded  by  a  gastro-enterostomy.  The  cardiac 
pouch  is  dealt  with  as  though  it  were  the  whole  stomach. 

If  both  pouches  require  to  be  drained,  a  double  gastro- 
enterostomy may  be  performed,  as  suggested  by  Weir  and 
Foote.  A  long  loop  of  the  jejunum  close  to  the  flexure  is  iso- 
lated and  is  united  to  the  two  pouches  by  two  separate 
anastomoses.     Each  pouch,  therefore,  drains  into  this  loop.     I 


OPERATIONS   FOR   HOUR-GLASS    STOMACH. 


279 


Fig.  105. — The  operations  for  hour-glass  stomach:  i,  Gastrogastrostomy; 
2,  double  gastro-enterostomy  (Weir);  3,  gastroplasty  (the  line  of  incision);  4, 
gastroplasty  (the  line  of  suture) ;  5  and  6,  partial  gastrectomy;  7,  Kammerer's 
operation;    8,  gastro-enterostomy. 


280  ABDOMINAL   OPERATIONS. 

have  never  given  this  operation  a  trial,  but  it  is  one  which  would 
probabh^  prove  successful. 

2.  Gastroplasty  is  an  operation  the  role  of  which  is  very 
limited.  It  is  applicable  onl}^  to  those  cases  in  which  a  narrow 
stricture  is  present  in  the  absence  of  induration,  active  ulcera- 
tion, or  external  adhesion.  In  mam"  of  the  recorded  cases  it 
is  noted  that  there  was  "  recoA'ery  without  reHef ."  It  is  probable 
that,  as  with  p^doroplast}^  the  operation  will  be  abandoned  in 
favour  of  worthier  methods.  The  cases  to  which  it  is  suited  are 
few,  and  more  successful  operations  can  be  practised  even  in 
them.  The  operation  consists  in  making  a  long  transverse  in- 
cision or  slightly  cur\'ed  incision  through  the  stricture,  and  con- 
tinuing the  incision  well  onwards  into  the  healthy  stomach-wall 
of  both  pouches.  The  incision  should  be  at  least  4  inches  in 
length.  The  transverse  incision  is  now  made  into  a  vertical 
one  by  applying  a  pair  of  clips  at  the  middle  of  the  upper  and 
lower  edges,  and  drawing  them  as  far  apart  as  possible.  The 
wotmd  is  then  sutured.  It  is  the  operation  of  p3doroplasty 
appHed  to  the  body  of  the  stomach. 

Dr.  Kammerer,  of  New  York,  has  adopted  a  modification  of 
gastroplasty  that  w^ill  reHeve  the  operation  of  many  of  its  ob- 
jections. His  method  bears  the  same  relation  to  gastroplasty 
as  Finney's  operation  does  to  pyloroplasty.  His  description 
is  as  follows:  "Beginning  at  the  lowest  point  of  the  constric- 
tion, a  running  suture  was  applied  through  the  serous  and  mus- 
cular coats,  bringing  the  vertical  edges  of  both  compartments 
of  the  stomach  into  close  approximation  along  their  posterior 
margins.  An  inverted  V-shaped  incision  was  now  made  through 
the  suture  thickness  of  the  stomach- wall,  about  j  inch  to  either 
side  of  the  Lembert  suture.  The  posterior  wound  edges  were 
now  brought  together  with  another  running  suture  from  within, 
the  same  procedure  being  then  applied  to  the  anterior  edges 
from  without.  The  final  act  of  the  operation  consisted  in  re- 
enforcing  the  anterior  suture  with  a  running  Lembert  stitch, 
and  placing  a  few  extra  sutures  at  the  lowest  point  of  the  stomach 


OPERATIONS   FOR   HOUR-GLASS    STOMACH. 


281 


through  the  serous  and  muscular  coats,  where  tension  would 
naturally  be  greatest."     The  patient  made  an  excellent  recovery. 

3.  Gastrogastrostomy  or  Gastro-anastomosis. — This  opera- 
tion was  first  performed  by  Wolfler  in  1894.  He  made  verti- 
cal incisions  7  cm.  in  length  into  the  dependent  pouches  on  each 
side  of  the  central  constriction,  and  united  these  so  as  to  form 
a  free  passage  beneath  the  isthmus. 

The  stomach  is  clamped  on  each  side  of  the  isthmus,  and  the 
clamps   are   surrounded  with   hot   machintoshes.     A   suture   is 


Fig.  106. — Hour-glass  stomach.     The  dotted  lines  indicate  the  position  of  the 
openings  in  the  operation  of  gastrogastrostomy. 

then  passed  through  the  serous  and  muscular  coats  of  the  part 
of  the  stomach,  on  each  side,  below  the  isthmus,  reaching  from 
it  to  the  greater  curvature.  The  needle  is  then  temporarily 
laid  aside.  The  incisions  are  then  made  in  front  of  the  suture 
line,  through  all  the  coats  to  the  mucosa,  a  large  ellipse  of  which 
is  excised.  A  continuous  suture,  picking  up  all  the  coats,  is 
then  passed  along  the  cut  margins  posterior  and  then  anterior 
until  the  opening  is  completely  encircled.  The  original  needle 
which  had  been  laid  aside  is  again  picked  up,  and  an  anterior 


282 


ABDOMINAL   OPERATIONS. 


line  of  sutures  is  completed.  The  operation,  in  fact,  is  precisely 
the  same  as  the  operation  of  gastro-enterostomy,  save  that  the 
stomach  is  embraced  by  both  clamps  instead  of  by  one  onty. 
Sedgwick  Watson  in  1895  successfully  performed  gastro- 
gastrostomy  in  a  different  manner.  The  incisions  in  the  two 
segments  of  the  stomach  were  transverse.  The  pyloric  por- 
tion of  the  viscus  was  folded  over  the  cardiac,  Avith  the  isthmus 


Fig.  107. — Hour-glass  stomach.  The  application  of  clamps  and  the  method 
of  suture  in  gastrogastrostomy.  The  details  are  the  same  as  in  the  operation 
of  gastro-enterostomy. 


as  a  hinge,  and  the  two  stitched  together  with  an  elliptical  line 
of  sutures  before  being  opened.  The  anastomosis  was  then 
made  by  incising  the  wall  of  the  compartment  which  now  lay 
anterior,  and  through  the  opposite  side  making  an  opening  into 
the  cardiac  pouch  in  the  centre  of  the  elliptical  area  which  had 
been  surroimded  by  the  suture.  This  method  has  never  been 
repeated,  so  far  as  I  know. 


OPER.\TIONS   FOR   HOUR-GLASS    STOMACH. 


28- 


4.  Partial  gastrectomy  will  more  often  be  practised  in  cases 
of  cancer  than  in  cases  of  simple  disease.  In  cancer  a  wide  ex- 
cision is  necessary,  upon  the  lines  laid  down  in  the  chapter  deal- 
ing with  operations  for  malignant  disease  of  the  stomach.  When 
the  mass  of  ulcer  or  growth  has  been  removed,  an  end-to-end 
approximation  of  the  stomach  can  be  made,  or  both  cut  ends 
may  be  closed  and  an  anastomosis  made  between  the  cardiac 
pouch  and  the  jejunum. 


Eh.v/maH:f- 


Fig.  loS. — Partial  gastrectomy  for  hour-glass  stomach  (Cotfey). 

5.  Digital  Divulsion  or  Dilatation. — Operations  of  all  kinds 
upon  hour-glass  stomachs  may  be  made  difficult  by  the  adhesion 
of  the  ulcer  whose  contraction  is  responsible  for  the  deformity. 
Adhesion  to  the  anterior  abdominal  wall,  to  the  liver,  or  pos- 
teriorly to  the  pancreas  may  be  so  strong  that  the  operative 
manipulations  are  greatly  embarrassed.  A  separation  of  the 
stomach  from  the  anterior  abdominal  wall  is  always  possible, 
though,  as  in  cases  of  my  own,  a  portion  of  the  abdominal  wall 
has  to  be  removed,  or  the  stomach  laid  open  in  so  doing. 

When  the  stomach  is  adherent  posteriorly,  or  when,  owing 


284 


ABDOMINAL   OPERATIONS. 


to  the  infinite  complexity  of  adhesions,  the  cardiac  pouch  cannot 
be  reached,  the  constriction  between  the  two  pouches  may  be 
dilated  b}^  the  fingers  until  a  free  communication  exists  below 
the  cardiac  and  pyloric  segments.  In  one  case  I  was  unable  to 
do  more  than  this.  The  mass  in  the  stomach  I  took  to  be,  with 
the  experience  I  then  possessed,  malignant  and  irremovable. 
The  cardiac  pouch,  owing  to  adhesions,  was  beyond  the  possibility 
of  inspection  or  manipulation,  and  I  was,  therefore,  compelled 


\- 


f.  : 


/  -v 


■^>L 


'  -Ui^f 


\«:     ^  ■ 


Fig.   109. — Partial  gastrectomy  for  hour-glass  stomach  (Coffey). 

to  be  content  with  a  retrograde  dilatation  of  a  very  narrow  con- 
striction. To  my  surprise  the  patient  made  a  perfectly  un- 
eventful recovery;  she  rapidly  gained  over  three  stones  in 
weight,  and  to  this  day  remains  well,  all  trace  of  a  tumour 
having  disappeared. 

A  full  account  of  the  subject  of  hour-glass  stomach  with  a 
record  of  my  cases  will  be  found  in  the  "British  Medical  Journal," 
February  20,  1904,  p.  413.     I  have  now  operated  on  54  cases. 


CHAPTER  XV 

THE   OPERATIVE   TREATMENT   OF   CANCER  OF    THE 

STOMACH. 

The  surgical  treatment  of  cancer  of  the  stomach  still  leaves 
much  to  be  desired.  The  medical  treatment  is  now,  as  it  always 
has  been,  absolutely  hopeless,  and  still  involves  a  mortality  of 
100  per  cent.  The  crying  need  in  cases  of  carcinoma  not  only 
of  the  stomach,  but  of  all  other  parts  of  the  alimentary  canal, 
is  for  earlier  diagnosis,  and  the  chance  of  earlier  surgical  treat- 
ment. Amongst  the  notable  achievements  of  surgery  in  recent 
years,  chiefly  as  a  result  of  the  work  in  the  Mayo  Clinic,  is  the 
proof  that  in  a  large  proportion  of  cases  the  onset  of  cancer  in  the 
stomach  is  not  a  new  and  unaccountable  thing,  but  is,  on  the  con- 
trary, a  tardy  development  upon  an  earlier  condition  which  for 
years  has  clamoured  for  recognition. 

I  am,  of  course,  well  aware  that  all  cases  of  cancer  of  the 
stomach,  unhappily,  do  not  come  to  the  surgeon.  No  one  but 
the  surgeon  can  do  any  good  to  patients  so  afflicted.  Yet  there 
is  a  strange  timidity  of  approach  to  the  surgeon  which  is  unac- 
countable, and  far  too  often  the  favourable  period  in  the  history 
of  a  case  is  allowed  to  slip  away  before  any  recognition  of  the 
real  conditions  is  attempted.  It  is  true,  then,  and  must  be  ad- 
mitted, that  when  the  surgeon  speaks  of  the  work  which  passes 
under  his  hand  he  is  not  speaking  of  the  whole.  Nor  is  any  one 
else.  Neither  the  physician  nor  the  post-mortem  investigator 
knows  the  whole  range  of  cases ;  indeed,  each  sees  far  less  nowa- 
days than  the  surgeon.  The  view  of  the  latter,  therefore,  if  not 
all-embracing,  is  doubtless  wider  than  that  of  any  one  else.  The 
experience  of  the  surgeon  shows — and  here  geographical  considera- 
tions seem  to  matter  little— that  roughly  two  out  of  three  of  all 
patients  who  come  for  relief  from  a  condition  of  carcinoma  of  the 

28s 


286  ABDOMINAL   OPERATIONS. 

stomach  give  a  histon^  of  inveterate  and  recurring  dyspepsia  OA^er 
a  stretch  of  many  months  or  years.  No  one  knows  so  well  as 
the  surgeon,  for  he  made  and  repeats  daily  the  discoveries,  that 
such  a  history  does  not  always  mean  that  there  is  a  chronic  ulcer 
of  the  stomach,  healing  and  breaking  down  afresh,  during  all  that 
time.  But  though  we  are  grown  chary  of  making  a  diagnosis 
of  "gastric  ulcer"  with  that  ease  and  certitude  which  formerly 
attached  to  the  physicians  of  all  countries,  we  can  and  do  make  an 
accurate  diagnosis  in  a  large  proportion  of  the  cases,  if  only  those 
patients  are  allowed  to  be  suffering  from  ' '  gastric  ulcer ' '  who  can 
hardly  be  supposed  to  be  the  victims  of  any  other  organic  lesion. 
The  surgeon  who  walks  by  sight  and  not  b}"  faith  knows  that 
a  gastric  ulcer  is  a  real  thing,  though  so  many  impostors  have 
claimed  his  attention.  In  the  majority  of  the  cases  of  gastric  car- 
cinoma the  history  given  of  earlier  attacks  makes  it  almost  certain 
that  these  were  due  to  a  veritable  ulcer  of  the  stomach.  There 
may  be,  I  fully  admit,  errors  in  this  estimate;  but  making  all  the 
allowances  that  our  operative  experience  warns  us  to  be  necessar\^ 
there  can  be,  I  think,  no  doubt  at  all  that  a  genuine  chronic  gas- 
tric ulcer  has  been  the  cause  of  that  dyspepsia  of  which  recurring 
attacks  are  noted.  In  one  of  these  attacks,  perhaps  after  an  inter- 
val of  months  or  years  of  freedom,  something  different  is  noticed. 
The  attack  is  heralded  in  the  old  way;  at  first  no  difference 
between  it  and  the  others  may  be  observed.  But  by  degrees  it 
is  realised  that  something  worse  is  occurring.  The  symptoms, 
which  in  earlier  attacks  were  so  easily  amenable  to  careful  treat- 
ment, to  rest,  to  sparing  diet,  and  so  forth,  have  now  become  more 
severe  and  incoercible.  Relief  does  not  come  from  the  measures 
which  before  have  been  so  instanth'  successful.  ^Moreover, 
weight  is  more  rapidly  lost,  anaemia  may  develope.  and  anorexia 
is  most  persistent  and  distressing.  This  is  the  occasion,  all  other 
and  more  favourable  occasions  having  lapsed,  when  instant — 
it  can  hardly  be  called  precocious — surgical  treatment  should  be 
urged.  The  patient  has  now  arrived  at  middle  life,  or  has  passed 
it,  and  the  diagnosis  of  cancer  ma}'  tentativeh'  be  made  and  should 


OPER.\TIVE  TREATMENT  OF  CANCER  OF  STOMACH.     287 

be  acted  upon  with  alacrity.  Surgical  intervention  for  purposes 
of  inquiry  has  hardly  any  mortality  nowadays.  If  a  cancer  be 
found  and  a  resection  of  the  stomach  is  undertaken,  the  mortality 
will  vary  with  the  expertness  of  the  hands  which  practise  it. 
But  whatever  that  mortality  may  be,  it  cannot  attain  the  death- 
rate  of  inaction  and  of  "expectant"  or  medical  treatment,  which 
is  exactly  100  per  cent. 

It  was  urged  by  Dr.  W.  L.  Rodman  many  years  ago  that  re- 
section of  the  pyloric  end  of  the  stomach  for  the  ulcers  that  singly 
or  in  clusters  are  found  there  was  the  most  prudent  mode  of  treat- 
ment. In  his  clinic  at  Rochester  Dr.  W.  J.  Mayo  has  for  several 
years  resected  the  stomach  not  only  for  chronic  ulcers  in  the  vi- 
cinity of  the  pylorus,  but  also  for  those  tumours  which  might  be 
due  to  ulcer  or  might  be  due  to  cancer,  for  declared  cancer  and 
for  those  cancers  which,  though  evidently  not  curable  because  of 
the  enlargement  of  distal,  secondary  glands,  or  other  visceral  de- 
posits, were  yet  removable.  In  his  so  safe  hands  resection  has 
hardly  any  greater  mortality  than  gastro-enterostomy.  This 
procedure  is  questionless  the  ideal  one.  It  has  afforded,  of  course, 
a  unique  series  of  specimens  for  investigation.  Drs.  Wilson  and 
MacCarty  conclude  from  their  examination  of  all  the  material  so 
furnished  that  in  71  per  cent,  of  these  cases  of  cancer  of  the  stom- 
ach the  malignant  process  is  engrafted  upon  a  simple  one,  that 
cancer  is  really  due  to  a  secondary  change  which  starts  in  the 
edge  of  an  ulcer  of  long  standing.  My  own  material,  far  less  in 
quantity,  bears  out  their  contention.  It  has  been  shewn  that  in 
the  base  of  these  ulcers  tending  to  cancer  the  mucosa  has  gone, 
leaving  only  scar  tissue;  in  the  overhanging  border  of  the  ulcers 
the  mucosa  is  proliferating  and  some  epithelial  cells,  nipped  off 
b}^  scar  tissue,  are  shewing  all  the  stages  of  aberrant  proliferation 
with  infiltration  of  the  surrounding  tissues  and  metastases  in 
the  lymphatic  vessels  of  the  stomach  wall.  The  truth  of  these 
observations  is  hardly  yet  admitted  by  those  whose  inquiry  has 
been  based  only  upon  specimens  found  in  the  post-mortem  room 
or  on  the  shelves  of  the  museums — upon  parts,  that  is,  that  have 


288  ABDOMINAL   OPERATIONS. 

been  long  dead,  and  subjected,  no  doubt,  to  the  man}^  changes 
which  death  and  swift  decay  bring  in  every  cell.  There  is  need 
to  develope  a  science  of  "histolog}^  of  the  living"  to  supplement 
and  explain  the  "pathology  of  the  living. "  Upon  the  post-mor- 
tem table  only  the  final  dilapidated  ruin  of  the  disease  is  seen; 
in  specimens  removed  during  life  the  disease  in  its  earlier  stages 
can  be  scrutinised.  The  material  upon  which  the  pathologist 
has  formerly  worked  has  not  been  favourable  to  the  discovery  of 
the  truth ;  the  sources  of  eternal  truth  were  poisoned. 

A  review  of  the  cases  which  have  been  under  my  own  care 
has  convinced  me  that  though  the  histor}^  especially  in  so  far 
as  it  tells  of  former  attacks  of  chronic  gastric  ulcer,  may  awaken 
a  keen  suspicion  as  to  the  presence  of  a  carcinoma  in  the  stomach, 
and  though  all  the  ancillar^^  evidence  to  be  derived  from  the 
chemical  examination  of  the  stomach  contents  may  go  towards 
a  confirmation  of  the  diagnosis,  there  is  only  one  means  of  making 
an  assured  diagnosis  in  an  early  stage.  An  inspection  of  the 
parts,  and  this  alone,  and  that  indeed  not  always,  can  give  us  the 
information  upon  which  a  probable  diagnosis  can  be  made.  It  is 
necessary  for  us  to  realise  that  by  any  other  methods  than  this 
one  a  positive  diagnosis  of  cancer  in  the  stage  when  it  is  capable 
of  successful  treatment  is  almost  impossible.  If  the  patients 
who  are  suffering  from  this  most  insidious  and  most  terrible  dis- 
ease are  to  have  any  fuller  prospect  of  relief,  or  of  cure,  the  use  of 
the  exploratory  operation  must  be  greatly  increased.  I  depre- 
cate more  strongly,  I  believe,  than  most  surgeons  the  adoption 
of  the  ' '  explorator}^  incision ' ' ;  but  every  argument  and  all  ex- 
perience shew  that  in  cases  of  carcinoma  of  the  stomach  no  other 
method  than  this  offers  any  slenderest  hope  for  the  betterment  of 
the  present  deplorable  condition  of  affairs.  But  before  we  are 
entitled  to  advise  any  patient  to  undergo  this  operation  we  must 
be  confident  that  there  is  a  well-grounded  suspicion  that  some 
condition  not  admitting  of  remedy  by  any  other  than  surgical 
means  will  be  found. 

Indications  for  Operation  in  Chronic  Gastric  Diseases. — I  think 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH.     289 

that  an  operation  should  be  advised  in  the  following  circum- 
stances : 

(a)  In  all  cases  of  chronic  gastric  ulcer.  The  recent  experi- 
ence of  surgeons  has  shewn  that  a  diagnosis  of  chronic  gastric 
ulcer  can  be  made  with  fair  accuracy,  and  that  not  only  the  pres- 
ence but  also  the  position  of  the  ulcer  can  be  sometimes  predicted. 
When  repeated  "attacks"  occur  it  is  idle  to  consider  any  other 
than  operative  treatment,  for  nothing  else  can  give  permanent 
relief.  If  any  attack  occurs  in  a  patient  over  forty  years  of  age 
the  need  for  surgical  intervention  becomes  urgent. 

(b)  When  gastric  stasis  is  present.  This  is  a  condition  the 
existence  of  which  is  easily  determined.  If  there  are  symptoms 
suggesting  structural  disease  in  a  stomach  incapable  of  empty- 
ing itself  completely  in  from  ten  to  twelve  hours,  then  the  condi- 
tions which  exist  are  mechanical,  and  can  be  remedied  by  none 
other  than  mechanical  means. 

(c)  When  a  tumour  is  present.  The  tumour  may  be  simple 
or  malignant,  but  research  is  better  conducted  by  inspection  than 
by  any  other  means  at  our  disposal. 

In  these  three  conditions  medical  treatment  may  do  something 
to  relieve,  it  can  do  nothing  to  cure.  There  is  accordingly  no 
reason  for  delay  in  advocating  operation.  If  this  is  done,  and 
done  early,  many  cases  of  carcinoma  that  now  drift  quietly  into 
the  inoperable  stage  may  be  saved. 

The  position  seems  now  to  be  this — that  there  are  no  signs  or 
symptoms  clearly  indicative  of  the  presence  of  gastric  cancer; 
there  is  no  refinement  of  clinical  inquiry  nor  any  endowment  of 
clinical  acumen  which  will  enable  a  confident  diagnosis  to  be 
made  in  an  early  stage;  inspection  of  the  stomach  during  an  op- 
eration carried  out  when  definite  faults  in  its  working  are  known 
will  permit  of  the  early  discovery,  or  of  the  prevention  of  a  cer- 
tain proportion  of  the  cases  of  cancer.  The  surgeon  must  not 
ask  the  physician  for  a  sign  which  will  reveal  the  presence  of  this 
disease  to  him,  but  he  can  and  should  require  that  those  condi- 
tions which  are  only  to  be  remedied  by  operative  measures  should 

VOL.    I — 19 


290  ABDOMINAL   OPERATIONS. 

be  referred  to  him  not  in  their  advanced  or  terminal  stages,  but 
at  the  earliest  moment  of  their  recognition.  The  success  which 
has  followed  the  surgical  treatment  of  gastric  disorders  justifies 
this  simple  request. 

THE  LYMPHATIC  SYSTEM  OF  THE  STOMACH. 

As  I  have  already  pointed  out,  an  accurate  knowledge  of  the 
lymphatic  system  of  the  stomach,  as  of  other  organs,  is  essential 
if  the  operative  treatment  of  malignant  disease  therein  occurring 
is  to  be  attended  with  any  degree  of  success. 

The  lymph-vascular  and  lymph-glandular  arrangements  in 
and  around  the  stomach  have  been  very  carefully  studied  in  re- 
cent years  by  many  observers.  Among  these  Most  ("Archiv. 
f.  klin.  Chir.,"  1899,  lix,  175),  Cuneo  ("De  I'envahissement 
du  Systeme  lymphatique  dans  le  Cancer  de  I'estomac, "  Thesis, 
Paris,  1900;  and  again  in  "Travaux  de  Chir.  Anat.-Clinique, " 
par  H.  Hartmann,  1903,  page  244),  Borrmann  (Das  Wachstum 
und  die  Verbreitungswege  des  Magencarcinoms, "  Jena,  1901), 
Lengemann  ("Verhandl.  d.  Deut.  Gesellsch.  f.  Chir.,"  1902,  483), 
Polya  and  v.  Navratil  ("Deut.  Zeit.  f.  Chir.,"  1903,  Ixix,  437), 
Jamieson  and  Dobson  ("Lancet,"  1907,  i,  1061)  have  done  work 
of  the  highest  value.  The  investigations  of  Most,  Borrmann,  and 
Lengemann  were  inspired  by  Mikulicz,  to  whom  is  due  the  credit 
of  first  demonstrating  the  principles,  and  indicating  the  methods 
upon  which  the  rational  operative  treatment  of  cancer  of  the 
stomach  must  be  based. 

The  greater  part  of  the  work  of  investigation  has  been  carried 
out  upon  the  bodies  of  foetuses  or  infants,  and  the  lymphatic  in- 
jections have  been  made  after  the  method  of  Gerota.  It  is  stated 
by  Polya  and  von  Navratil  that  the  number  of  the  glands 
increases  considerably  in  adult  life,  either  by  the  division  of  the 
original  glands  or  by  their  fresh  development  from  lymph-vessels. 
Though  the  results  obtained  by  these  investigations,  especially 
those  of  Cuneo  and  Polya  and  von  Navratil,  are  of  the  highest 
value,  they  are  not  to  be  accepted  without  discrimination  as  in- 


OPERATIVE  TREATMENT  OP^  CANCER  OF  STOMACH.     29 1 

dicating  the  lines  of  surgical  procedure.  For  we  have  as  yet 
little  or  no  knowledge  of  the  changes  which  the  lymphatic  system 
undergoes  between  foetal  life  or  early  infancy  and  the  period  of 
life  at  which  cancer  is  found.  In  this  period  changes  in  the  num- 
ber of  the  lymphatic  glands  undoubtedly  occur,  and  it  is  possible 
that  vessels,  which  in  the  foetus  run  to  distant  glands,  are  inter- 
cepted by  newly  developed  glands  in  the  adult.  Of  the  changes 
in  the  vessels  little  is  known,  but  there  is  evidence  to  shew  that 
in  the  aged  they  are  withered  and  shrunken  or  obliterated  in  some 
degree,  so  that  they  are  no  longer  easy  channels  for  the  convey- 
ance of  cancer  cells.  It  must  also  be  remembered  that  when 
cancer  develops  in  any  part,  say  in  the  pylorus,  the  cancer  cells 
are  carried  in  the  lymph-stream  in  the  direction  which  is  usually 
followed.  This  direction  is  indicated  in  the  specimens  in  which 
the  injection  method  of  Gerota  has  been  performed.  But  in 
cases  of  cancer  the  early  involvement  of  certain  lymph- vessels, 
their  plugging  by  cancer  cells,  or  the  implication  of  a  single  gland, 
may  be  enough  to  disturb  the  normal  direction  of  the  lymph  cur- 
rent. In  such  circumstances  an  erratic  course  may  be  pursued 
by  the  cancer  cells  carried  away  from  the  growth. 

The  stomach-wall  is  freely  supplied  with  vessels,  which  com- 
mencing blindly  beneath  the  surface  epithelium,  surround  the 
glands,  forming  periglandular  and  sub  glandular  plexuses.  From 
the  latter,  large  vessels  arise,  which,  passing  through  the  muscu- 
laris  mucosas,  enter  into  the  large  submucous  plexus.  From  this 
again  wide  vessels  pass  outwards  to  the  subserous  network, 
which  lies  immediately  beneath  the  peritoneal  covering.  In 
these  vessels  there  are  innumerable  valves  which  give  to  the  in- 
jected trunks  a  beaded  appearance;  in  the  lymph  plexuses  within 
the  walls  of  the  stomach  are  no  valves.  When  an  injection  of 
the  submucous  or  subserous  plexuses  is  made  the  fluid,  though  it 
is  distributed  widely,  yet  shews  a  definite  inclination  to  pass  in 
certain  directions.  Certain  territories  are  therefore  mapped  out 
in  the  stomach,  a  little  arbitrarily  perhaps,  but  nevertheless  with 
useful  purpose,   to  indicate  the  normal  lymphatic  watersheds. 


292  ABDOMINAL  OPERATIONS. 

Cuneo  describes  three  such  areas.  One  hes  along  a  line  drawn 
from  the  apex  of  the  fundus  (approximately)  to  the  middle  of  the 
pylorus  in  such  manner  as  to  separate  the  upper  two-thirds  of 
the  stomach  from  the  lower  third;  the  lymphatics  of  this  area 
drain  upwards  to  the  lesser  curvature  and  the  cardia.  The  part 
of  the  stomach  lying  below  this  line  is  divided  into  two  at  the  mid- 
point of  the  greater  curvature,  a  point  which  lies  vertically  below 
the  right  margin  of  the  oesophagus  as  it  enters  the  stomach,  and 
which  indicates  the  separation  between  the  areas  of  the  stomach 
supplied  respectively  by  the  right  and  left  gastro-epiploic  arteries. 
The  lymph- vessels  in  this  lower  part  of  the  stomach  drain  towards 
the  greater  curvature,  those  on  the  right  obliquely  towards  the 
pylorus,  those  on  the  left  towards  the  spleen. 

The  vessels  all  drain  into  lymphatic  glands,  which  are  placed 
in  certain  groups.  A  description  of  these  may  be  given  before 
the  connexion  between  the  vessels  and  the  glands  is  described. 

The  lymphatic  glands  connected  with  the  stomach  follow 
closely  the  distribution  of  the  arteries  to  the  stomach.  The  names 
given  to  the  glands  are  therefore  most  conveniently  those  which 
the  arteries  bear.  It  would  be  unnecessary  to  refer  to  this  were 
it  not  that  there  has  been,  as  there  too  often  is  in  matters  ana- 
tomical, a  great  confusion  of  names  and  a  needless  multiplication 
of  them.     The  following  gland  groups  will  be  described: 

I.  The  Glands  Associated  with  the  Coronary  Artery. — The 
glands  in  connexion  with  the  coronary  artery  are  divisible  into 
certain  groups. 

(a)  Lower  coronary. 

(b)  Upper  coronary. 

(c)  Paracardial  glands. 

(a)  Lower  Coronary  Glands. — These  glands  lie  along  the  left 
half  of  the  lesser  curvature,  in  association  with  the  descending 
branch  of  the  coronary  artery,  between  the  layers  of  the  gastro- 
hepatic  omentum.  Their  position  is  apt  to  vary;  they  are 
usually  close  to   the   artery,  but  may,  according  to  Letulle,  be 


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The  arteries  and  lymphatics  of  tlie  stomach.      Posterior  view. 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH.     293 

embedded  in  the  wall  of  the  stomach,  or  they  may  slip  down- 
wards on  the  posterior  surface  of  the  organ.  They  are  few  in 
number  in  the  foetus,  and,  as  a  rule,  are  found  only  on  the  cardiac 
half  of  the  lesser  curvature;  they  are  larger  and  more  numerous 
towards  the  cardia,  and  extend  up  to  the  right  paracardial  glands. 
They  receive  their  afferent  vessels  from  the  whole  length  of  the 
lesser  curvature.  The  vessels  from  the  pylorus  run  very  obliquely 
in  the  wall  of  the  stomach  before  reaching  the  glands,  those  from 
the  middle  of  the  stomach  less  obliquely,  the  vessels  all  radiating, 
fanwise,  to  the  gland  group.  The  number  of  these  glands  is  very 
variable.  Poly  a  and  von  Navratil  found,  as  a  rule,  only  two  or 
three;  Lengemann,  in  one  specimen,  discovered  14.  Their  effer- 
ents  discharge  into  the  upper  coronary  group. 

(b)  Upper  Coronary  Glands. — This  group  lies  along  the  main 
trunk  of  the  coronary  artery  as  it  is  embraced  by  the  peritoneal 
fold  known  as  the  falx  coronaria.  They  are  the  most  constant 
and  the  most  important  glands  of  this  region,  and  are  found  on 
all  sides  of  the  arterial  trunk.  Below,  the  chain  is  continuous 
with  the  lower  coronary  group,  and  above  with  the  glands  around 
the  coeliac  axis,  at  the  upper  border  of  the  pancreas.  Their 
afferent  lymph- vessels  come  from  the  lower  coronary  group,  and 
from  the  next  two  groups  to  be  described;  in  addition  they  re- 
ceive lymph- vessels,  as  Polya  and  von  Navratil  pointed  out, 
direct  from  the  lesser  curvature  of  the  stomach.  (This  observa- 
tion, which  is  confirmed  by  Jamieson  and  Dobson,  is  one  of  great 
significance  from  the  surgical  point  of  view.) 

(c)  The  paracardial  glands,  with  their  lymphatics  form,  as 
Most  appropriately  says,  a  "girdle"  round  the  cardia  of  the  stom- 
ach. They  are  divided  by  some  authors  into  two  or  three 
groups,  according  as  they  lie  behind,  to  the  left  or  right  of  the 
cardia.  The  right  paracardial  glands  are  constant;  they  re- 
ceive, according  to  Polya  and  von  Navratil,  their  afferents  direct 
from  the  lesser  curvature  of  the  stomach,  and  from  the  retro- 
paracardial  glands  and  the  left  paracardial.  Their  efferents  dis- 
charge into  the  upper  coronary  glands.     The  left  paracardial : 


294  ABDOMINAL   OPER.\TIONS. 

Their  efferents  discharge  into  the  upper  coronary  glands.  The 
left  paracardial  glands,  according  to  Cuneo,  are  often  wanting, 
but  Polya  and  von  Navratil  found  them  constantly  and  Jamieson 
and  Dobson  confirm  this.  Both  these  observers  found  them  occa- 
sionalh^in  large  numbers  (six  and  seven).  Their  efferents  come 
from  the  fundus,  in  front  and  behind,  and  discharge  into  the  right 
paracardial  or  upper  coronary  groups.  Behind,  a  retrocardial 
gland  may  intercept  a  few  vessels. 

II.  The  Glands  Associated  with  the  Hepatic  Artery. — It  is 
more  especially  in  connexion  with  these  glands  that  a  needless 
confusion  in  the  nomenclature  has  crept  in.  The  glands  may  be 
divided  into  separate  groups : 

f       A   loiver  group  lyirig  along  the  right 

I   gastro-epiploic  artery  below  the  greater 

I   curvature  of  the  stomach. 

I        An  upper  group  lying  near  the  bifur- 

(a)  Glands  in  con-  I    cation  of  the  gastroduodenal  artery. 

nexion  with  the  right   ]        (The  name  "subpyloric"  is   given  to 

gastroduodenal     art-    |   the  two  divisions  by  Polya  and  von  Nav- 

ratil,  but  only  to  the  upper  group  by 

I   Jamieson  and  Dobson) . 

I        A  retropyloric  group  lying  by  the  side 

of  the  gastroduodenal  artery  behind  the 

[  pylorus. 

ih)  Glands  in  connexion  with  the  trunk  of  the  hepatic  artery, 

right  supra  pancreatic  glands. 
ic)  An  occasional  gland  lying  beside  the  pyloric  artery,  the 
p^doric  arter}',  the  suprapyloric  gland. 

(a)  Glands  in  Connexion  Tx'itli  tlie  Right  Gastro-epiploie  Artery. — 
These  glands  are  usually  described  as  lying  in  two  groups,  a  lower 
and  an  upper,  between  which  is  a  distinct  interval. 

The  lower  group,  usually  two  to  seven  in  number,  lies  along 
the  right  gastro-epiploic  artery,  below  the  greater  curvature  of 
the  stomach,  between  the  la^^ers  of  the  great  omentum.  The 
glands  are  not  found  to  the  left  of  the  midpoint  of  the  greater 
curvature;    they  lie  usually  on  the  lower  side  of  the  artery  they 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH.     295 

accompany,  and  they  are  apt  to  stray  downwards  in  the  great 
omentum.  Their  afferent  vessels  come  from  the  lower  third  of 
the  stomach  along  the  right  half  of  the  greater  curvature.  Their 
efferents,  without  exception,  discharge  into  the  glands  of  the 
upper  group. 

The  upper  group,  consisting  of  four,  five,  or  more  glands,  lies 
beyond  the  pylorus,  in  the  angle  formed  by  the  first  and  second 
parts  of  the  duodenum,  at  or  near  the  point  of  bifurcation  of  the 
gastroduodenal  artery.  They  receive  afferent  vessels  from  the 
pylorus,  and  from  the  duodenum  and  the  efferent  vessels  from  the 
lower  group.  The  course  taken  by  their  efferent  vessels  is  in 
three  directions: 

(a)  To  the  chain  along  the  hepatic  artery,  the  retropyloric 

glands  being  sometimes  interposed. 

(b)  Across  the  pancreas,  or  through  the  gland,  obliquely  to 

the  glands  around  the  coeliac  axis. 

(c)  To  glands  lying  in  the  root  of  the  mesentery;   this  is  the 

direction  taken  by  the  majority  of  the  efferents. 

The  retropyloric  glands,  few  in  number  and  inconstant,  lie 
behind  the  pylorus,  on  the  front  of  the  pancreas,  by  the  side  of 
the  gastroduodenal  artery.  They  receive  afferents  from  the 
group  just  described,  and  also  direct  from  the  hinder  surface  of 
the  pylorus  and  duodenum.  These  glands  are  described  by  Most 
and  Cuneo  and  are  figured  by  Cuneo  and  Lengemann.  They 
were  not  seen  by  Jamieson  and  Dobson;  but  of  their  occasional 
existence  there  can  be  no  doubt.  It  may  be  that  they  are  only 
aberrant  members  of  the  gastro-epiploic  glands,  or.  more  prob- 
ably prolapsed  members  of  the  group  of  glands  along  the  hepatic 
artery. 

(6)  The  -Glands  in  Connexion  with  the  Main  Trunk  of  the 
Hepatic  Artery.  Right  Suprapancreatic  Glands. — These  glands 
are  few  in  number  and  lie  beside  the  trunk  of  the  hepatic  artery, 
along  the  upper  border  of  the  pancreas.  They  receive  afferent 
vessels,  as  Most  and  Polya  and  von  Navratil  have  shewn,  di- 
rectly from  the  upper  border  of  the  pylorus,  a  "  suprapyloric " 


296 


ABDOMINAL   OPERATIONS. 


gland  being  occasionally  placed  in  the  path  of  one  or  more  ves- 
sels, and  also  efferents  from  the  upper  gastro-epiploic  group. 
(The  glands  are,  therefore,  both  primary  and  secondary.)  Their 
efferents  go  to  the  glands  around  the  coeliac  axis. 

(c)  Occasionally  a  gland  is  placed  along  the  pyloric  artery 
to  the  right  of  the  lesser  curvature.  It  intercepts  a  vessel  from 
the  pylorus,  and  transmits  its  efferents  to  the  right  suprapan- 
creatic  group. 

III.   The  glands  along  the  splenic  artery  are  surgically  the 


Fig.  no. — The  lymphatic  areas  of  the  stomach:  a,  The  area  from  which 
the  lymphatic  vessels  drain  into  the  coronary  glands;  h,  the  area  from  which 
the  vessels  drain  into  the  glands  along  the  greater  curvature;  c,  the  "isolated" 
area. 


least  important  of  all,  for  they  drain  only  the  "isolated"  area 
of  the  stomach.  One  or  two  small  glands  lie  in  the  hilum  of  the 
spleen  and  in  the  gastrosplenic  omentum.  They  draw  their  affer- 
ents  from  the  left  half  of  the  greater  curvature  and  from  the 
fundus;  their  efferents  go  to  the  next  group. 

The  main  group  lies  along  the  trunk  of  the  splenic  artery,  at 
the  upper  border  of  the  pancreas ;  they  are  the  left  suprapancre- 
atic  glands.  They  draw  afferents  from  the  glands  in  the  hilum 
of  the  spleen,  and  also  vessels  directly  from  the  fundus  of  the 


OPEIL\TIVE   TREATxMENT   OF   CANXER   OF    STOMACH.  297 

stomach.  Their  efferents  discharge  into  the  glands  at  the  coeHac 
axis. 

IV.    The   glands   in   connexion  with   the    coeliac   axis    are 

the  recipients  of  afferent  vessels  from  all  the  gland  groups  pre- 
viously described.  They  are  few  in  number,  large  in  size,  lie  in 
the  fork  formed  by  the  coronary  artery  and  the  splenic  artery  as 
the}^  arise  from  the  coeliac  axis.  Some  of  their  efferents  discharge 
directly  into  the  receptaculum  chyli,  and  others  pass  behind  the 
pancreas  to  the  glands  lying  in  the  root  of  the  mesentery. 


Fig.  III. — Diagram  to  shew  the  mode  of  spreading  of  a  pjdoric  cancer,  the 
lymphatic  invasion,  and  the  line  of  division  of  the  stomach  in  partial  gastrec- 
tomy. Note  especially  that  the  whole  of  the  lesser  curvature  is  removed.  The 
arrows  indicate  the  direction  of  the  lymphatic  currents. 

From  the  above  description  it  will  be  seen  that  two  varieties 
of  glands  may  be  described  in  respect  of  their  vascular  afferents. 
There  are  glands  which  receive  vessels  directly  from  the  stomach, 
there  are  others  which  receive  only  the  efferents  vessels  from  other 
glands.  The  former  glands  are  described  as  "primary/'  the 
latter  as  ' '  secondary. ' '  There  are  certain  groups  which  are  both 
primary  and  secondary,  receiving  some  vessels  direct  from  the 
stomach,  and  other  vessels  from  glands  adjacent  to  them. 

The  distinction  between  the  primary  and  secondary  glands 
is  of  the  highest  importance  from  the  surgical  point  of  view,  be- 


298  ABDOMINAL  OPERATIONS. 

cause  it  is  clear  that  if  any  operative  treatment  of  carcinoma  of 
the  stomach  is  to  be  considered  radical,  the  first  cordon  of  glands 
at  least  must  be  removed  along  with  the  growth.  Leaving  aside 
the  "isolated  area"  of  the  stomach,  wherein  primary  growths 
are  almost  unknown,  and  invasion  by  growths  commencing  else- 
where is  very  rare,  the  primary  glands  are: 

The  lower  coronary. 

The  upper  coronary. 

The  right  paracardial. 

The  suprapyloric. 

The  right  suprapancreatic. 

The  gastro-epiploic,  upper  and  lower. 

The  retropyloric,  when  present. 

In  cases  of  cancer  of  the  pylorus  or  prepyloric  region  all  these 
glands  may  be  invaded  by  growth  conveyed  along  vessels  directly 
from  the  stomach.  To  the  affection  of  these  primary  glands 
Cuneo  gives  the  name  ' '  immediate  adenopathies " ;  to  the  affec- 
tions of  the  secondary  glands,  the  name  ''distant  adenopathies ^ 
Jamieson  and  Dobson  describe  an  additional  primary  gland. 
They  have  found  a  vessel  which,  arising  from  the  upper  border 
of  the  pylorus,  separates  itself  from  other  vessels,  and  turns  to 
the  right  behind  the  duodenum,  to  end  in  a  gland  lying  behind  the 
head  of  the  pancreas,  on  the  lower  end  of  the  common  duct,  a 
gland  of  the  biliary  chain.  Poly  a  and  von  Navratil  in  one  case 
found  an  efferent  vessel  going  from  a  retropyloric  gland  to  a 
gland  in  the  hilum  of  the  liver. 

Glandular  invasion  occurs  early  in  cancer  of  the  stomach. 
According  to  Cuneo,  it  is  found  in  all  cases  at  autopsy  and  in 
87.5  per  cent,  of  the  specimens  removed  by  gastrectomy.  To 
determine  the  existence  of  carcinoma  a  minute  examination  of 
the  glands  microscopically  is  necessary,  for,  as  Carle  and  Fantino 
("Archiv.  f.  klin.  Chir.,"  1898,  Ivi,  226)  have  shewn,  the  glands 
may  be  found  grossly  enlarged,  yet  not  invaded  by  growth, 
whereas  small  glands  are  found  full  of  growth.  The  invasion  of 
the  glands  of  the  lesser  curvature  is  that  most  commonly  found; 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH.     299 

it  is  present,  according  to  Cuneo,  in  91.4  per  cent,  of  cases  (opera- 
tion specimens) ;  the  glands  of  the  greater  curvature*  are  affected 
in  62.5  per  cent,  of  cases. 

There  are  certain  features  of  carcinoma  of  the  stomach  other 
than  those  connected  with  the  glandular  implication  which  it  is 
essential  to  bear  in  mind  in  planning  and  in  carrying  out  a  ' '  rad- 
ical" operation.  These  are  concerned  with  the  local  enlarge- 
ment of  the  growth,  the  invasion  of  the  lesser  curvature,  and  the 
invasion  of  the  duodenum.  Cuneo  and  Borrmann  have  studied 
these  points  with  conspicuous  care. 

1.  The  Local  Increase  of  the  Growth. — When  the  growth  is  in- 
spected from  either  its  mucous  or  serous  surfaces,  no  adequate 
idea  of  its  real  size  is  obtained,  for  it  is  in  the  submucous  layer 
that  the  widest  extension  takes  place.  For  some  distance  be- 
yond the  edge  of  the  palpable  or  visible  growth  a  vertical  section 
of  the  stomach-wall  shews  a  continuous  infiltration  of  the  sub- 
mucosa,  and  beyond  this  scattered  nodules  may  be  seen,  nodules 
which,  according  to  Borrmann,  are  still  connected  with  the  main 
growth.  The  extent  of  this  submucous  invasion  cannot  be  pre- 
dicted, but  it  is  never  safe  to  allow  for  it  a  margin  of  less  than  3 
cm.  (Cuneo)  when  the  division  of  the  stomach  is  made  in  partial 
gastrectomy. 

2.  The  invasion  of  the  lesser  curvature  is  very  pronounced  in 
the  great  majority  of  cases.  In  Borrmann's  series  of  63  cases  he 
found  the  following  disposition. 

The  two  curvatures  were  equally  invaded  in  32  cases — 52 

per  cent. 
The  greater  curvature  was  more   invaded  than  the  lesser  in 

19  cases — 30  per  cent. 

*It  is  sometimes  said  (see  Jamieson  and  Dobson,  page  1065)  that  there  is  a 
great  discrepancy  in  the  estimates  of  the  frequencj^  of  glandtilar  complications 
in  the  statistics  of  Cuneo  and  Lengemann.  The  fact  is  not  realised  that  Lenge- 
mann's  percentages  refer  to  the  number  of  glands  affected  out  of  the  total  num- 
ber of  glands  which  were  present,  whereas  Cuneo's  percentages  refer  to  the  num- 
ber of  cases  in  which  any  glandular  involvement  occurs.  If  Lengemann' s  cases 
are  examined  in  the  same  manner  as  Cuneo's  (as  is  easily  done,  full  details  being- 
given),  it  will  be  found  that  their  results  are  almost  identical. 


300  ABDOMINAL   OPERATIONS. 

The  lesser  curvature  was  free  in  three  cases. 
The  greater  curvature  was  free  in  i  case. 
Both  curvatures  were  free  in  i  case. 


Cuneo  found  the  lesser  curvature  affected  in  19  cases  out  of 
22,  and  explains  the  discrepancy  between  his  figures  and  Borr- 
mann's  as  being  due  to  the  shrinkage  the  lesser  curvature  rapidly 
undergoes  after  removal  of  the  specimen  from  the  body.  The 
greater  implication  of  the  lesser  curvature  is  to  be  expected  if  the 
commonest  place  of  origin  of  the  growth  is  borne  in  mind.  Cuneo 
has  shewn,  moreover,  that  the  extension  of  the  growth  along  the 
lesser  curvature  is  in  reality  an  invasion  of  the  stomach  along  the 
lymphatic  vessels.  The  removal  of  the  whole  length  of  the  lesser 
curvature  is,  therefore,  an  essential  part  of  any  operation,  as 
V.  Mikulicz,  and  those  who  worked  under  him — Most  and  others 
— were  the  first  to  shew. 

3.  Invasion  of  the  Duodenum. — From  the  time  of  Rokitansky 
and  Brinton  to  Mikulicz  and  Most,  all  observers  commented 
upon  the  integrity  of  the  duodenum  in  cases  of  cancer  of  the 
stomach.  This  integrity  is  more  apparent  than  real.  Carle  and 
Fantino  shewed  that  in  many  of  their  cases  the  bowel  was  in- 
volved, and  Cuneo  and  Borrmann  have  demonstrated  the  fre- 
quency and  the  extent  of  this  invasion.  In  11  cases  examined 
by  Cuneo  the  duodenum  in  7  was  healthy,  in  4  it  was  invaded, 
but  in  only  i  case  was  the  disease  found  i  cm.  beyond  the  pylorus. 
Borrmann,  in  63  cases,  found  the  duodenum  invaded  in  19  cases; 
in  9  of  these  the  bowel  was  diseased  at  the  point  of  section ;  in  2 
cases  the  disease  extended  over  2  cm.  in  a  continuous  growth  on- 
wards from  the  pylorus.  The  indication,  therefore,  is  that  the 
removal  of  the  whole  of  the  first  portion  of  the  duodenum  is  nec- 
essary in  all  cases  of  gastrectomy  for  carcinoma.  Some  informa- 
tion of  value  is  to  be  derived  from  an  examination  of  those  speci- 
mens, removed  by  partial  gastrectomy,  in  which  it  is  evident  that 
the  operation  has  been  incomplete.  Borrmann,  in  his  exhaustive 
examination  of  63  specimens  (p.  333),  found  no  less  than  20  in 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH.     3OI 

which  it  was  evident  that  a  complete  removal  of  the  growth  had 
not  been  accomplished.  In  these  20  cases  there  were  13  in  which 
the  incompleteness  was  on  the  side  of  the  lesser  curvature,  in 

8  at  the  cardiac  end,  in  i  at  the  duodenal  end,  and  in  4  at  both 
ends. 

In  2  cases  the  greater  curvature  had  been  too  scantily  removed, 
in  I  on  the  stomach  side  only,  in  the  other,  both  on  the  stomach 
and  the  duodenal  sides. 

In  5  cases  both  lesser  and  greater  curvatures  were  insuffi- 
ciently removed.  In  2  this  insufficiency  involved  the  duodenal 
extremity  above  and  below,  and  the  lesser  curvature;  in  i  the 
duodenal  extremity  above  and  below ;  in  2  the  cardiac  end  of  the 
two  curvatures;  that  is  to  say,  that  in  16  of  the  20  incomplete 
operations  it  was  the  lesser  curvature  that  was  involved,  and  in 

9  of  the  20  it  was  the  duodenum.  On  the  other  hand,  it  was 
only  in  4  cases  that  the  greater  curvature  on  the  stomach  side  was 
involved. 

After  a  study  of  all  the  facts  previously  discussed,  we  are  in  a 
position  to  lay  down  the  lines  upon  which  an  operation  for  the 
removal  of  a  malignant  growth  beginning  in  the  pyloric  region 
of  the  stomach  should  be  based.  It  is  essential  that  the  whole 
growth  should  be  taken  away,  and  such  a  margin  beyond  the 
visible  and  palpable  tumour  as  shall  ensure  that  the  outlying 
nodules  are  within  the  lines  of  section;  that  all  the  lesser  curva- 
ture should  be  removed;  that  one  half  of  the  greater  curvature 
should  be  removed;  that  an  inch  at  least  of  the  duodenum 
should  be  removed;  that  all  the  "primary"  glands  at  least 
should  be  taken  (these  are  the  lower  and  upper  coronary,  the 
right  paracardial,  the  suprapyloric,  the  right  suprapancreatic, 
the  right  gastro-epiploic,  upper  and  lower,  and  the  retropyloric) . 
The  removal  of  all  these  parts  is  possible,  and  therefore  the 
somewhat  mournful  view  of  the  possibilities  of  the  surgical 
treatment  of  cancer  of  the  stomach  taken  by  Lengemann,  Polya 
and  von  Navratil,  Jamieson  and  Dobson,  is  not  justified.  The 
difficulties  to  be  encountered  will  chiefly  lie  in  the  removal  of 


^02 


ABDOMINAL   OPER.\TIOXS. 


the  right  suprapancreatic  glands,  but  that  these  difficulties  are 
exaggerated  is,  I  think,  quite  certain.  In  several  cases  I  have,  by 
using  the  "gauze  stripping"  method,  removed  the  glands  with- 
out any  injury  either  to  the  hepatic  artery  or  to  the  pancreas. 

The  following  are  the  details  of  the  operation  of  partial  gas- 
trectomy : 

PARTIAL  GASTRECTOMY. 

The  operation  is  carried  out  in  the  following  manner:    An 
ample  incision  is  made  in  the  middle  line,  reaching,  as  a  rule, 


Fig.  1 12. — Gastrectomy  shewing  the  ligature  of  the  pyloric  arterj^  and  vein. 


from  the  ensiform  cartilage  to  the  umbilicus.  The  central  in- 
cision is  more  convenient  than  the  lateral  incision,  which  is  com- 
monly employed  for  the  operation  of  gastro-enterostomy ;  it 
gives  easier  and  more  immediate  access  to  all  parts  of  the  opera- 
tion area.  An  inspection  of  the  extent  of  the  cancerous  invasion 
of  the  stomach  itself,  of  its  adhesion  to  the  pancreas  or  abdominal 
wall  or  liver,  of  the  number  and  position  of  any  glandular  enlarge- 
ments, and  finally  of  the  liver,  peritoneum,  and  parts  immediately 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH.     303 

in  the  neighbourhood  to  discover  if  secondary  growth  be  present, 
is  rapidly  and  carefully  made.  Neither  adhesions  nor  the  in- 
volvement of  lymphatic  glands  preclude  removal  of  the  stomach, 
though  they  may  render  the  mechanical  difficulties  rather  more 
serious.     When  a  resection  has  been  decided  upon,  fiat  gauze 


Fig.  113. — Partial  gastrectomy.      The  growth  is  shewn,  and  the  position  in 
which  the  gastro-epiploic  artery  is  secured  on  the  greater  curvature. 

swabs,  wrung  out  of  hot  saline  solution,  are  packed  around  the 
stomach  so  as  to  afford  a  barrier  between  the  field  of  work  and 
the  general  peritoneal  cavity.  As  a  rule,  two  layers  of  swabs  are 
mtroduced,  the  first  consisting  of  very  large  ones,  which  are  un- 
changed throughout  the  operation,  and  the  second  of  smaller 
ones,  which,  when  soiled,  are  changed  at  once.     No  care  is  too 


304  ABDOMINAL  OPERATIONS. 

punctilious  so  long  as  absolute  security  of  the  peritoneal  cavity 
is  ensured. 

Around  the  wound  edges  the  rubber  and  gauze  squares  are 
tucked.  The  transverse  colon  with  the  omentum  is  allowed 
to  lie  out  of  the  abdomen  with  the  stomach,  in  order  to  render 
easier  the  manipulations  concerned  with  securing  the  integrity 
of  the  middle  colic  arter\^  During  the  time  the  colon  is  not  en- 
gaged immediately^  in  the  operation  it  is  covered  with  a  rubber  and 
gauze  sheet  kept  moist  and  warm.  I  find  it  a  great  convenience 
to  make  at  once  the  opening  in  the  transverse  mesocolon  which 
will  presently  be  used  for  the  purpose  of  enabling  the  jejunum 
to  be  passed  through  it  when  the  anastomosis  with  the  stomach 
is  made.  Through  this  opening  the  finger  can  from  time  to  time 
be  passed,  and  in  this  manner  the  exact  position  of  the  middle 
colic  arten,^  and  of  the  gastroduodenal  artery  can  be  determined. 

The  first  step  in  the  operation  consists  in  tearing  through 
the  gastrohepatic  omentum  close  to  the  liver.  As  a  rule  this 
structure  is  of  exceeding  tenuity,  and  its  vessels  require  no  liga- 
ture, but  occasionally,  and  especially  towards  the  p^doric  end  of 
it,  one  or  more  little  vessels  may  need  to  be  secured.  At  once  the 
fingers  of  the  left  hand  pass  into  the  lesser  sac,  and  feeling  behind 
the  stomach  are  able  to  ascertain  whether  any  inseparable  ad- 
hesions exist  between  the  stomach  and  the  pancreas,  and  gener- 
ally to  determine  the  conditions  of  the  growth  on  its  posterior 
aspect. 

The  arteries  which  supply  the  stomach  are  then  secured.  It 
was  formerly  my  practice  to  secure  the  coronary  artery  at  the 
very  first,  but  this  is  by  no  means  easy,  and  is  indeed  very  un- 
satisfactory; for,  approached  from  the  front,  it  is  ph3'sically  im- 
possible to  ligature  the  vessel  close  to  its  origin  from  the  coeliac 
axis.  The  highest  possible  point  should  be  chosen  for  the  di- 
vision of  the  artery,  otherwise  the  highest  group  of  coronary 
glands,  which  we  know  to  be  primary,  will  be  left  behind.  The 
early  ligature  of  the  coronary  artery  is  then  not  only  difficult, 
but  it  is  dangerous  and  inefficient  and  a  ligature  applied  to  it  at 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH.     305 

the  beginning  of  the  operation  may  sHp  and  sharp  haemorrhage, 
not  easily  controlled,  may  occur.  The  first  vessel  to  be  secured, 
then,  is  the  pyloric  artery,  which  is  given  off  close  to  the  upper 
border  of  the  pylorus,  by  the  hepatic  artery.  It  may  arise  sepa- 
rately or  in  a  common  trunk  with  the  gastroduodenal  artery; 
if  separately,  it  is  surrounded  by  a  double  ligature  and  divided 
as  far  away  from  the  stomach  as  possible.  From  the  point  of 
section  a  cut  or  tear  is  made  through  the  peritoneum  above  the 
pylorus  and  the  first  part  of  the  duodenum,  in  such  manner  as  to 
secure  that  all  the  glands  and  fat  are  stripped  upwards  to  the 
stomach.     Care  is  taken  not  to  wound  the  common  duct. 

W.  J.  Mayo  mentioned  ("Jour.  Amer.  Med.  Assoc,"  1910, 
i,  1608)  that  in  one  case  of  his  the  duct  was  wounded,  and  bile 
drained  from  it  for  some  days.  The  left  forefinger  is  then  passed 
behind  the  duodenum  from  above  downwards,  separating  the 
first  part  of  the  intestine  from  the  pancreas,  and  is  made  to  pro- 
ject at  the  lower  border  of  the  bowel,  well  to  the  right  of  the  sub- 
pyloric  group  of  glands.  As  the  finger  is  withdrawn  two  clamps 
are  passed  along  its  track,  and  the  duodenum  is  firmly  embraced 
by  them  both.  The  distal  clamp  is  of  the  curved  pattern  shewn 
in  the  figure,  the  blades  being  grooved  longitudinally.  The 
duodenum  is  then  cut  across  about  i  inch  from  the  pylorus,  as 
close  to  the  distal  clamp  as  possible,  the  knife  shaving  the  bowel 
off  so  that  nothing  projects  beyond  the  blades.  At  once  the 
mucosa  of  the  proximal  end  is  thoroughly  cauterised  and  rendered 
sterile.  To  prevent  the  clamp  from  slipping,  a  couple  of  liga- 
tures may  be  passed  through  the  stomach  on  the  cardiac  side  of 
the  clamp  and  tied  over  the  clamp  blades.  At  this  point,  as 
the  cut  end  of  the  duodenum  is  turned  over  to  the  left,  the  gas- 
troduodenal artery  may  be  seen  to  give  off  the  right  gastro-epi- 
ploic  artery,  and  one  or  other  of  these  vessels  is  now'  secured. 
As  the  aneurysm  needles  surround  the  vessels,  the  colon  and 
omentum  are  turned  upwards  so  as  to  display  the  middle  colic 
artery,  which  must  be  clearly  seen  to  be  intact. 


3o6 


ABDOMINAL   OPERATIONS. 


The  distal  end  of  the  duodenum  is  now  closed  in  the  following 
manner  (Parker-Kerr  method,  slightly  modified) : 

The  clamp  is  held  vertically  in  the  right  hand  of  the  assistant, 
with  the  tip  of  the  blades  pointing  to  the  surgeon's  right.  The 
suture  begins  at  the  extreme  upper  border,  on  the  left  of  the  clamp. 


Fig.  114. — Author's  clamp,  modified  from  the   Parker-Kerr  clamp,  for  use  in 
closing  the  cut  end  of  the  duodenum  or  other  parts  of  the  small  intestine. 

Here  a  stitch  is  taken,  about  Yi  inch  from  the  clamp,  and  at  right 
angles  to  it.  The  needle,  when  withdrawn,  is  taken  across  the 
front  of  the  clamp  blades,  Mobile  the  clamp  itself  is  twisted  by  the 
assistant  over  to  the  left  so  as  to  make  the  surface  of  the  bowel  to 
the  right  of  the  clamp  jjresent.     In  this  a  turn  of  the  needle  is 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH. 


307 


taken,  about  I4  inch  from  the  clamp,  parallel  to  it,  and  starting 
as  close  to  the  upper  edge  as  possible.  This  stitch  is  drawn 
tight,  so  that  a  thread  is  now  seen  to  pass  over  the  front  of  the 
needle,  from  the  first  to  the  second  turn  of  the  needle.     Again  the 


Fig.  115. — Partial  gastrectomy.  The  pyloric  artery  has  been  secured,  and 
the  gastrohepatic  omentum  divided  (fewer  ligatures  than  are  shewn  are  gener- 
ally sufficient) .  The  gastro-duodenal  artery  has  been  secured  and  the  duodenum 
is  about  to  be  divided.  The  smaller  drawings  shew  the  method  of  closure  of 
the  duodenal  end. 


clamp  is  twisted  by  the  assistant  until  the  left  side  of  the  bowel 
presents,  and  in  this  a  turn  of  the  needle  is  taken  about  >4  inch 
from  the  clamp,  and  parallel  to  it.  So  the  stitch  proceeds,  first 
on  one  side  of  the  bowel  and  then  on  the  other,  as  the  clamp  is 


308 


ABDOMINAL   OPERATIONS. 


turned  in  the  assistant's  hands  and  each  aspect  of  the  bowel  is 
made  prominent.  The  last  turn  of  the  needle  is  taken  on  the 
side  opposite  to  that  on  which  the  stitch  began,  and  it  is  longi- 
tudinal (as  was  the  first  turn) ,  the  needle  being  entered  near  the 
clamp,  at  its  tip,  and  taken  along  the  bowel  in  a  direction  away 


Fig-.    1 1 6. — Partial    gastrectomy.      The  duodenum    closed.      The    gastrohepatic 

omentum  divided. 


from  t?ie  clamp.  The  stitch  is  then  grasped  at  each  end  by  the 
surgeon,  while  the  assistant  opens  and  disengages  the  clamp. 
Then  at  once  the  stitch  is  drawn  tight  by  pulling  with  both 
hands,  and  instantly  the  cut-  edges  infold,  and  the  closure  of  the 
bowel  is  secure.  The  suture  is  then  made  to  return  along  the 
bowel  to  the  starting-point,  where  it  is  knotted  and  drawn  tight. 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH. 


309 


SO  that  the  cut  end  of  the  gut  puckers  up  very  tightly.  I  gener- 
ally introduce  one  or  two  interrupted  sutures  over  the  dimpled 
end  of  the  bowel,  though  probably  this  is  not  necessary,  and  fin- 
ally one  or  two  sutures  are  passed  through  the  pancreas  and  the 
duodenum,  so  as  to  make  the  closed  end  of  the  bowel  fit  accu- 
rately  against   the   anterior  surface  of  the  head  of  the   gland. 


Fig.  117. — Partial  gastrectomy.  The  stomach,  wrapped  in  gauze,  is  turned 
over  to  the  left,  and  the  coronary  artery  is  now  easily  secured  close  to  the  aorta. 
This  is  the  only  method  by  which  the  artery  can  be  easily  tied  at  a  point  suffi- 
ciently high  to  ensure  that  the  primary  glands  which  lie  on  the  vessel  are  below 
the  point  of  division. 


The  next  step  consists  in  the  division  of  the  gastrocolic  omentum 
along  the  greater  curvature  of  the  stomach,  or  rather  along,  and 
as  close  as  possible  to,  the  upper  margin  of  the  transverse  colon. 
The  concavity  which  the  duodenum  makes  in  its  second  portion 
is  cleaned  of  all  the  fat  which  lies  within  it,  fat  which  contains 
often-times  one  or  more  possibly  affected  glands.  It  is  most 
important  to  see  that  this  subpyloric  group  of  glands  and  all  the 


3IO 


ABDOMINAL   OPERATIONS. 


' '  dropped  glands ' '  from  this  group  lying  in  the  gastrocolic  omen- 
tum are  included  in  the  parts  to  be  removed.  As  the  stomach 
is  lifted  away  from  the  pancreas  a  few  retropyloric  glands 
may  be  seen,  or  some  adhesions  to  the  pancreas  discovered. 
These  adhesions  may  be  light  and  easily  divided,  or  they  ma}'  be 
firm  and  inseparable.     If  the  latter,  then  it  is  better  not  to  tear 


Fig.  ii8. — Partial  gastrectomy.  The  coronary  artery  being  divided,  the 
"anchor"  which  held  the  stomach  has  gone.  The  stomach  is  now  turned  well 
over  to  the  left,  and  gastro-enterostomy  performed.  It  is  quite  easy  to  do  this, 
because  the  hold  on  the  stomach  allows  it  to  be  drawn  up  and  retained  easily 
in  position. 


them  away  from  the  pancreas,  but  with  a  sharp  knife  to  take  a 
superficial  shaving  from  the  gland.  There  is  no  danger  in  this, 
provided  that  the  duct  of  the  gland  is  not  reached.  There  may  be 
a  little  bleeding  but  a  hot,  moist  swab,  or  a  few  fine  sutures  of 
catgut  soon  cause  its  arrest.     A  series  of  ligatures  is  passed  by  the 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH. 


311 


aid  of  the  aneurysm  needle,  through  the  gastrocoUc  omentum 
from  right  to  left  and  as  the  needle  lies  in  position  for  each  liga- 
ture the  transverse  colon  and  the  omentum  are  turned  upwards 
so  as  to  make  sure  that  the  trunk  of  the  middle  colic  artery  is  not 


Fig.  119. — Partial  gastrectomy.  The  dotted  line  shews  the  position  of  the 
gastro-enterostomy,  which  has  already  been  performed.  The  clamps  are  placed 
on  the  stomach;  between  them  the  stomach  is  divided.  The  line  of  section  and 
the  gastro-enterostomy  opening  are  generally  made  about  i  inch  further  to  the 
left  than  is  shewn  in  the  figure. 


embraced.  It  is  impossible  to  emphasize  too  strongly  the  need 
for  care  and  caution  in  this  matter.  Operators,  so  distinguished 
and  so  careful  as  Kocher  and  Finney,  have  ligatured  the  middle 
colic  artery  with  the  result  that  gangrene  of  the  colon  has  oc- 
curred, or  such  pallor  or  lividity  of  it  has  been  seen  before  the 


312  ABDOMINAL   OPERATIONS. 

completion  of  the  operation  that  a  resection  of  the  intestine  in- 
volved has  been  necessaty.  One  after  another  the  ligatures  are 
passed,  below  the  arch  of  the  gastroepiploic  vessels,  until  the  mid- 
point of  the  greater  curvature  of  the  stomach  is  reached.  Be- 
yond this  point,  for  the  reasons  already  given,  it  is  not  necessary 
to  go.  At  this  point,  therefore,  the  gastroepiploic  vessels  are 
ligatiured  and  divided.  The  ligature  of  these  large  trunks  is  best 
done,  I  think,  at  this  stage  of  the  operation,  though  I  have  many 
times  placed  a  preliminary  double  ligature  at  this  point,  before 
the  duodenum  is  cut  across. 

i\s  soon  as  this  stage  in  the  operation  is  reached,  it  will  be 
found  easy  to  turn  over  the  stomach  to  the  left,  the  posterior  sur- 
face being  now  to  the  front,  so  that  the  anterior  surface  of  the 
pancreas  is  seen  in  all  its  length.  Into  the  lesser  sac  a  large  hot 
swab  is  now,  or  at  an  earlier  stage  of  the  operation  has  been, 
packed.  By  pulling  a  little  forcibly  on  the  stomach  the  origin 
of  the  coronary  artery  from  the  coeliac  axis  is  now  readily  seen  and 
felt.  It  is  a  perfectly  simple  matter  to  surround  it  with  an 
aneurysm  needle  and  to  ligature  it  in  two  places  close  to  its  origin. 
The  upper  coronary  group  of  glands  must  remain  with  the  stom- 
ach when  the  vessel  is  divided,  and  to  make  sure  of  this  it  is  as 
well  to  strip  the  glands  downwards  from  the  vessel  and  to  leave 
the  trunk  quite  bare.  On  the  instant  that  the  vessel  is  divided 
the  stomach,  freed  from  its  main  anchorage,  is  readily  drawn  down- 
wards and  can  be  more  easily  turned  over  to  the  left.  While  it 
is  held  in  this  position  the  anastomosis  with  the  jejunum  is  made. 
It  is  now  quite  easy  to  do,  for  the  stomach,  held  in  the  assistant's 
hand,  cannot  slip  away  from  the  clamp.  If  the  gastro-enteros- 
tomy  is  performed  after  the  stomach  has  been  divided,  it  is  often 
a  matter  of  extreme  difficulty  to  grip  the  posterior  wall  of  the 
stomach  with  the  clamp  in  exactly  the  position  required,  and  it  is 
a  still  more  difficult  matter  to  prevent  it  from  slipping  away.  A 
small  rent  is  made  in  the  transverse  mesocolon,  and  the  first  few 
inches  of  the  jejunum  are  drawn  through.  The  clamps  are  ap- 
plied to  the  stomach  and  jejunum  in  such  manner  that  the  open- 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH. 


313 


ing  which  is  to  be  made  in  them  is  antiperistaltic — it  runs,  that 
is  to  say,  obhquely  from  the  lesser  curvature  above  downwards 
and  to  left  to  the  greater  curvature.  By  making  the  anastomosis 
in  this  way  a  rather  larger  portion  of  the  stomach  may  be  removed. 
Curved  clamps  are  more  easily  applied  than  straight  ones. 

The  anastomosis  is  now  performed  in  the  ordinary  manner. 


'^Y- 

^^ 

^^ 

^^y^__,-^ 

\           &^  ■/ 

-•^ 

^^fe^ 

^^^^ 

.>iii>fci^"Wf!^MBK 

^^^^fe 

^^     1 

\ 

T?S5«R 

r^^^^ 

1 
1 

ffl 

^9kL^ 

^Mwi 

1 

!■ 

\      Y^^ 

••             ^^^i 

^^w*^  ™ 

^^ 

- 1^" 

^^^ 

1 
j 

i 
i 

I-        "5°'?      ..    - -, 

^ 

Fig.    120. — Partial  gastrectomy.      Closure  of   the    stomach, 
with  the  jejunum  is  seen. 


The    anastomosis 


When  it  is  completed,  the  time  has  come  to  sever  the  stomach. 
This  is  done  between  two  pairs  of  large  curved  clamps,  which 
are  applied  so  that  their  convexities  lie  towards  the  pylorus. 
When  placed  in  this  manner,  the  lesser  curvature  of  the  stomach 
is  gripped  at  its  very  highest  point.  If  the  clamps  are  placed 
with  the  convexity  to  the  left,  it  will  be  found  that  the  tip  of  the 
highest  one  does  not  securely  grip  the  oesophageal  portion  of  the 


314  ABDOMINAL  OPERATIONS. 

lesser  curvature.  I  have  once  had  great  difficuhy  at  this  point 
in  the  operation  as  a  resuh  of  the  upper  end  of  the  divided  stom- 
ach receding  from  the  clamp.  To  prevent  this  the  reverse  appli- 
cation of  the  clamp  is  possibty  quite  sufficient,  but  in  addition  I 
always  introduce,  before  the  stomach  is  divided,  at  the  highest 
point,  one  or  two  sutures,  which  take  the  posterior  and  the  an- 
terior walls  on  each  side  of  the  line  of  the  intended  incision.  By 
holding  these  firmly  upwards  the  stomach  is  absolutely  pre- 
vented from  retraction.  When  the  clamps  are  secure,  the  stom- 
ach is  cut  across  about  3/^  inch  distal  to  the  line  of  the  gastro- 
enterostomy opening.  The  serous  and  muscular  coats  are  first 
divided,  back  and  front,  and  are  pushed  backwards  from  the 
mucosa,  which  is  then  divided  as  near  as  possible  to  the  proximal 
clamp.  The  whole  length  of  the  mucosa  is  now  thoroughly  cau- 
terised, or  still  better,  wiped  with  pure  carbolic  acid.  A  cat- 
gut suture,  which  takes  all  the  coats,  is  introduced,  beginning 
at  the  lesser  curvature  and  ending  at  the  greater.  It  is  an 
interlocking  suture,  the  individual  turns  of  which  are  placed 
close  together,  and  the  catgut  at  each  turn  is  drawn  as  tight 
as  possible.  This,  as  a  rule,  secures  all  vessels,  but  if.  when  the 
clamp  is  loosened,  any  bleeding  point  is  seen,  it  is  secured  with 
a  separate  stitch  or  a  ligature.  A  second  line  of  sutures  is  now 
inserted.  A  continuous  thread  of  Pagenstecher's  material  is 
used,  and  extends  from  the  lesser  to  the  greater  curvature,  in- 
folding the  former  line  of  sutures  securely.  The  needle  is  intro- 
duced on  each  surface  of  the  stomach  about  ^2  inch  from  the 
former  suture  line,  so  that  the  cut  end  of  the  stomach  is  deeply 
infolded. 

At  the  lower  end  it  has  sometimes  been  a  matter  of  difficulty 
to  me  to  secure  a  quite  satisfactory  appearance  of  closure.  Re- 
cently, instead  of  continuing  the  running  suture  the  entire  length 
of  the  incision,  I  change  its  character  about  an  inch  from  the  end, 
and  here  pass  the  needle  three  or  four  times  in  the  direction  of 
the  suture  line,  about  y2  inch  away  from  it  on  the  anterior  sur- 
face,  downwards  to  the   greater  curvature,   and  then  upwards 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH.     315 

along  the  posterior  surface  at  the  same  distance,  so  as  to  surround 
the  last  inch  or  so  of  the  divided  edge  of  the  stomach  by  a  purse- 
string  suture.  As  this  suture  is  tightened  the  suture  line  is 
pressed  inwards  and  buried.  A  few  more  interrupted  sutures 
may  here  and  there  be  necessary  and  finally  the  two  interrupted 
sutures  applied  at  the  lesser  curvature  before  the  stomach  was 
cut  across  are  tied. 

Glands  are  now  sought  along  the  hepatic  artery  at  the  upper 
border  of  the  pancreas — the  right  suprapancreatic  glands.  As  a 
rule,  none  are  found,  but  if  any  be  discovered,  they  can  be  strip- 
ped away  by  gauze  pressure,  especial  care  being  taken  to  avoid 
any  damage  to  the  trunk  of  the  hepatic  artery.  The  operation 
area  is  now  wiped  gently  over  with  hot  moist  swabs.  The  omen- 
tum and  the  transverse  colon  are  turned  upwards,  the  jejunum 
at  its  origin  pulled  upon,  until  the  gastro-enterostomy  line  is 
seen,  and  the  edges  of  the  divided  mesocolon  are  then  stitched  to 
the  gastrojejunal  suture  line  in  the  usual  manner.  A  final  in- 
spection of  the  whole  area  is  made,  and  the  omentum  then  turned 
vertically  upwards  to  lie  over  all  the  operation  area  and  to  make 
all  the  rough  places  smooth.  The  blood  lost  by  the  patient  in 
this  operation,  from  beginning  to  end,  should  be  less  than  an 
ounce.  Drainage  is  not  necessary  unless  the  pancreas  has  been 
deeply  injured  or  the  common  duct  wounded. 

The  immediate  union  of  the  duodenum  to  the  stomach  by 
the  method  of  Billroth  and  Kocher  is  not  to  be  recommended.  It 
is  not  easy  to  accomplish  even  after  the  duodenum  has  been  mo- 
bilised— it  leads  to  parsimony  in  the  removal  of  diseased  areas, 
and  is  apt  to  be  followed  by  a  stenosis  at  the  new  opening  which 
may  call  for  the  performance  of  gastro-enterostomy  in  the  future 
stages.  Throughout  the  operation  the  nicest  care  is  taken  to 
avoid  loss  of  blood,  the  exposure  of  viscera,  and  the  contamination 
of  the  operation  area.  Every  manoeuvre  is  carried  out  with  the 
daintiest  and  most  delicate  manipulations.  Rough  handling  or 
rough  wiping,  indeed,  roughness  of  an}^  kind,  is  to  be  scrupulously 
avoided.     Here,  as  always  in  the  abdomen,  the  light  hand  is  es- 


3i6 


ABDOMINAL   OPERATIONS. 


sential.  Patients  who  need  this  operation  are  often  seriously 
wasted,  and  their  tissues  are  drained  of  all  fluids.  Their  appear- 
ance often  suggests  desiccation.  It  has  fallen  to  me  very  often 
to  operate  upon  such  wasted  patients,  and  in  order  to  supply 
them  with  fluid  I  have  passed  a  stomach-tube  through  the  gastro- 


Fig.  121. — Kocher's  method  of  uniting  the  duodenum  to  the  posterior  surface 
of  the  stomach  after  partial  gastrectomy. 

enterostomy  opening  as  soon  as  it  is  made.  The  tube  passes  6 
or  10  inches  into  the  jejunum,  and  through  it  two  pints  of  pep- 
tonised  milk  with  a  little  brandy  are  slowly  poured,  while  the  sub- 
sequent stages  of  the  operation  are  completed,  and  the  parietal 
wound  is  being  secured.     The  patient,  indeed,  is  having  a  good 


OPERATIVE  TREATMENT  OF  CANCER  OF  STOMACH.     317 

meal  during  the  time  that  his  stomach  is  being  cut  away.  As 
soon  as  the  patient  returns  to  bed,  as  a  matter  of  routine,  the  con- 
tinuous administration  of  sahne  fluid  by  the  rectum  is  begun  and 
is  continued  for  twenty-four  or  forty-eight  hours.  It  is  really 
astonishing  to  see  how  fresh  and  bright  a  patient  looks  who  is 
in  this  manner  well  supplied  with  fluid.  There  is,  as  a  rule,  little 
or  no  shock  after  this  operation,  which  lasts  an  hour,  or  a  little 
longer,  in  the  ordinary  case. 

In  the  matter  of  oral  feeding,  the  customary  routine  after 
gastro-enterostomy  is  followed;  the  patient,  that  is  to  say,  is 
allowed  fluids  in  unrestricted  quantities.  It  is  fluid  the  patient 
needs,  and  the  more  he  can  take,  the  better. 

In  some  cases  anterior  gastro-enterostomy  may  have  to  be 
performed  instead  of  the  posterior  operation.  Since  I  adopted 
the  method  described  above,  the  performance,  that  is,  of  the  gas- 
tro- jejunal  anastomosis  before  the  detachment  of  the  stomach, 
I  have  never  had  to  resort  to  the  anterior  method.  Should  it 
ever  be  necessary,  the  usual  procedure  is,  so  far  as  possible,  car- 
ried out,  a  point  on  the  jejunum  about  15  to  18  inches  below  the 
flexure  being  chosen  for  the  new  orifice. 

Instead  of  closing  the  cut  end  of  the  stomach  and  making  an 
opening  from  the  posterior  surface  of  the  stomach  to  the  jejunum, 
Reichel  and  Wilms  have  suggested  that  the  cut  end  of  the  stom- 
ach should  be  united  in  all  its  length  to  the  jejunum.  I  have  no 
experience  of  the  method. 


CHAPTER  XVI. 

THE  CHOICE  OF  OPERATION  IN  CANCER  OF  THE  STOMACH. 

In  Pyloric  Cancer. — Surgeons  of  some  experience  in  opera- 
tions upon  the  stomach  are  divided  in  their  opinions  as  to  the 
better  operation  in  cases  of  malignant  disease  of  the  pylorus. 
On  the  one  hand  are  those  who,  believing  that  a  diagnosis  of 
malignant  disease  cannot  be  made  while  yet  the  disease  is  local, 
advocate  a  palliative  operation, — gastro-enterostomy, — with 
the  idea  of  giving  rest  to  the  diseased  area,  and  thereb}^  re- 
tarding growth,  as  in  colotomy  for  malignant  disease  of  the 
rectum.  On  the  other  hand  are  those  who,  having  been  tempted 
to  employ  a  radical  operation  in  some  favourable  case  or  series 
of  cases,  are  so  impressed  with  its  advantages  that  they  become 
apostles  of  a  broader  creed  and  advocate  local  extirpation.  My 
opinion  emphatically  is  that,  in  all  cases,  whenever  possible,  a 
radical  operation  should  he  attempted.  Under  present  con- 
ditions of  diagnosis  the  probability  is  that,  when  a  patient  is 
submitted  to  operation,  gastro-enterostomy  is,  in  general,  a 
safer  operation  than  pylorectomy.  But  although  the  comfort 
and  sense  of  well-being  of  the  patient  may  improve  A^ery  de- 
cidedly for  a  time  after  the  former  operation,  the  tumour  is 
still  slowly  enlarging  in  size,  and  will  eventually  cause  death. 
How  much  of  the  general  ill  health,  cachexia,  and  so  forth  are 
induced  by  absorption  from  the  growth,  by  necrotic  changes  in 
its  mass,  by  ulceration  and  hemorrhage  upon  the  surface,  is 
quite  unknown,  but  one  may  presume  that  such  influences  are 
not  trivial.  Krokiewicz  and  Pilliet  believe,  indeed,  that  cancer 
cachexia  is  the  result  of  intoxication  with  the  by-products  of 
metabolism  of  the  cancer-cells.  A  local  extirpation,  then,  even 
if  followed  by  a  recurrence,  will  probably  prolong  life  for  a  greater 
period  and  in  greater  comfort  than  a  gastro-enterostomy.     It 

,318 


CHOICE  OF  opi<:ration  in  cancer  of  stomach.         319 

was  doubtless  an  opinion  similar  to  this  which  led  Terrier  to 
remark  that  "the  best  form  of  gastro-enterostomy  was  done 
after  removal  of  the  pylorus."  But  increasing  experience  in 
the  most  competent  hands  tends  to  shew  that  in  properly 
selected  cases  pylorectomy  is  not  an  operation  of  very  grave 
risk,  and  is  an  operation  of  generous  promise. 

Partial  gastrectomy  in  the  early  days  of  its  employment 
was  an  exceedingly  serious  operation,  with  an  appalling  death- 
rate.  Latterly  the  mortality  is  seen  to  be  a  gradually,  but  per- 
sistently, diminishing  one. 

In  order  to  form  some  estimate  as  to  the  chances  of  life,  of 
the  condition  of  health,  and  of  the  relative  values  of  different 
operations  in  patients  afflicted  with  malignant  disease  of  the 
stomach,  it  is  desirable  to  enquire  closely  into  the  records  of  a 
number  of  cases,  preferably  in  the  practice  of  one  surgeon,  ob- 
served over  a  series  of  years.  The  fullest  account  of  the  sur- 
gical side  of  the  question  has  been  given  by  Kronlein,  of  Ziirich, 
and  by  von  Mikulicz,  of  Breslau.  The  questions  that  are  in 
urgent  need  of  settlement  are  the  following: 

1.  Will  a  palliative  operation  upon  the  stomach  prolong  life? 

2.  Will  it  make  the  remnant  of  life  more  tolerable?  Will  it 
make  the  patient  feel  that  the  ordeal  of  operation  is  justified  in 
the  greater  comfort  of  his  later  days  ? 

3 .  Will  a  resection  give  a  reasonable  prospect  of  cure  ? 

4.  Will  a  resection,  if  followed  by  recurrence,  give  increased 
length  of  days  and  better  health  ? 

It  is  necessary,  in  fact,  to  know  whether,  in  the  stage  in  which 
we  now  meet  with  the  cases,  an  operation  is  worth  doing,  and,  if 
it  is,  whether  it  should  be  palliative,  or  whether  an  attempt  should 
be  made  to  eradicate  the  disease. 

In  order  to  have  some  means  of  comparing  the  surgical  cases 
with  those  not  operated  upon,  it  is  necessary  that  exact  details 
should  be  kept  of  all  cases  coming  to  the  surgeon,  whatever  their 
destiny — to  operation,  to  internal  medication,  or  to  absence  of 
treatment — may  chance  to  be. 


320  ABDOMINAL   OPERATIONS. 

Kronlein  tabulates  the  cases  which  came  under  his  observa- 
tion from  April  i,  1881,  to  February,  1902.  All  the  cases  were 
recorded,  without  exception.  There  were  264,  and  the  follow- 
ing table  gives  a  brief  sketch  of  their  classification: 

A.   NOT  OPERATED   UPON. 

1 .  Inoperable 53 

2 .  Refusing  operation 14 

Total 67 

B.   OPERATED  UPON. 

Death  Under 
Operation. 

1.  Exploratory  laparotomies 73  7 — -9.5  per  cent. 

2.  Gastro-enterostomies 74  18 — 24.3     " 

3.  Gastrectomies 50  14 — 28.0      "      " 


Total 197  39 — 19.8     "     " 

Of  the  264  patients,  all  but  13  were  traced.  Of  these  13,  the 
majority  had  not  been  treated  by  operation,  and  not  one  of  them 
had  been  submitted  to  gastrectomy. 

The  fate  of  these  patients  is  shewn  in  the  following  table : 

Not  traced 13 

Dead 229 

In  consequence  of  operation 39 

Later,  from  intercurrent  disease 2 

' '     from  suicide i 

"      from  the  primary  carcinoma 166 

' '      from  recurrence  after  gastrectomy 21 

Living 22 

Gastro-enterostomies 9 

Gastrectomies 13 


Total 264 

Of  the  264,  it  will  be  seen  that  67  were  not  operated  upon  (25.3 
per  cent.).  In  53  of  these  an  operation  was  contra-indicated; 
in  14  it  was  refused  by  the  patients. 

Of  the  264,  73  had  exploratory  laparotomy  performed  (27.6 
per  cent.).  After  the  surgeon  had  opened  the  abdomen  and  had 
become  convinced  of  the  impossibility  of  radical  extirpation, 
the  abdominal  wound  was  closed. 

Of  the  73  patients,  7  died  within  the  first  week  after  operation 


CHOICE   OF   OPER.\TIONS    IN   CANCER   OF    STOMACH.  32 1 

(4  from  exhaustion,  2  from  pneumonia,  and  i  from  pulmonary 
embolism) . 

In  74  patients  gastro-enterostomy  was  performed.  At  first 
sight  this  number  appears  small,  but  Kronlein  has  laid  it  down 
as  a  rule  of  his  practice  that  in  cases  of  carcinoma  of  the  stomach, 
where  extirpation  is  impossible,  the  palliative -operation  of  gastro- 
enterostomy shall  not  be  performed  unless  there  is  evidence  of 
stenosis.  If  this  evidence  fails,  the  operation  becomes  merely 
"exploratory."  The  only  exception  that  has  been  made  is  in 
those  cases  in  which  there  has  been  marked  stagnation  of  food 
without  evidence  of  stenosis.  Of  the  74  gastro-enterostomies, 
18,  or  24.3  per  cent.,  died  under  the  operation. 

Fifty  patients  were  submitted  to  the  operation  of  gastrectomy. 
Of  these,  14  died  in  direct  consequence  of  the  operation.  Of  the 
total  264  cases,  therefore,  only  18.9  per  cent,  underwent  the  radi- 
cal operation.  One  of  the  50  was  the  well-known  case  of  total 
extirpation  of  the  stomach  performed  by  Schlatter. 

The  subjoined  table  shews  the  percentage  in  which  each  form 
of  operation  was  attempted : 

264  CASES. 

No  operation  in 25.3  per  cent. 

Operation  in 74.7     "      " 

Exploratory .27.6 

Gastro-enterostomy 28. o 

Gastrectomy 1S.9 

OPERATION  MORTALITY. 

Exploratory  laparotomy 9.5  per  cent. 

Gastro-enterostomy 24.3     "     " 

Gastrectomy 28.0     "      " 

In  order  to  obtain  a  comparison  between  the  life-chances  of 
those  patients  who  survive  operation  and  those  who  are  not 
operated  upon,  it  is  necessary  to  cancel  the  following: 

Patients  who  withdrew  after  examination 13 

"  "     did  not  survive  operation 39 

"     died  of  intercurrent  disease 2 

"     committed  suicide i 

Total 55 

VOL.  I — 21 


322  ■  ABDOMINAL   OPERATIONS. 

Deducting  these  55  from  the  total  of  264  we  have  209  patients, 
who  may  be  classified  thus : 

A.   NOT   OPERATED   UPON. 

1 .  Inoperable 51 

2.  Declining  operation 12  63 

B.    OPERATED   UPON. 

1.  Explorator}'  laparotomy 58 

2.  Gastro-enterostomy 54 

3 .  Gastrectomy 34  146 

Total 209 

The  report  as  to  these  209  cases  at  the  beginning  of  March, 
1902,  when  these  enquiries  were  concluded,  was  as  follows: 

Died  from  carcinoma  of  the  stomach 187 

Living 22 

There  died : 

A.   OF  THOSE   NOT   OPERATED   ON. 

1 .  Inoperable  cases 51 

2.  Declining  operation , 12  63 

B.   OF   THOSE   OPER.\TED   ON. 

1.  All  the  explorator}'  laparotomies 58 

2.  Of  the  gastro-enterostomies 45 

3.  Of  the  gastrectomies 21        124 

Of  those  operated  on  and  not  operated  on 187 

There  are  still  living : 

1.  Of  gastro-enterostomies 9 

2.  Of  gastrectomies 13  22 

Total 209 

The  duration  of  disease  in  patients  suffering  from  carcinoma 
of  the  stomach  was  also  reckoned.  It  was  found  that,  on  the 
average,  the  time  from  the  first  onset  of  symptoms  up  to  the  day 
of  the  patient's  admission  to  the  hospital,  or  up  to  the  day  of 
operation,  was  from  eight  to  nine  months.  Means  were  also 
taken  to  discover  the  number  of  days  from  the  patient's  ad- 
mission or  from  the  date  of  operation  to  the  patient's  death. 


CHOICE   OF   OPERATION   IN    CANCER   OF    STOMACH.  323 

The  duration  of  time  from  entrance  into  hospital  (time  of 
operation)  to  date  of  death: 

A.  In  the  non-operated  cases 102  days. 

B.  In  the  operated  cases: 

1.  Exploratory  laparotomies 114     " 

2.  Gastro-enterostomies 193      " 

3.  Gastrectomies , 520      " 

If  in  these  groups  we  sum  up  the  values  found  for  both  periods  of 
duration  of  the  disease,  we  gather  the  following  to  be  the  average 
time  for  the  whole  duration  of  the  carcinoma  from  the  onset  of 
the  first  symptoms  until  time  of  death : 

A.  In   the   non-operated,    9    months   and    102    days — about    12^ 

months. 

B.  In  the  operated  cases: 

1.  Exploratory  laparotomies,  9  months  and  114  days,   or    13 

months. 

2.  Gastro-enterostomies,    9    months    and    193    days,   or    15^ 

months. 

3.  Gastrectomies,  9  months  and  520  days,  or  26^  months. 

Kronlein,  from  this  experience,  draws  the  following  con- 
clusions : 

1.  That  carcinoma  of  the  stomach  without  operation  has  a 
fatal  termination  in  about  a  year. 

2.  That  gastro-enterostomy  prolongs  the  life  of  the  patients 
suffering  from  this  disease  for  about  three  months,  on  the  average. 

3.  That  gastrectomy,  so  far  as  it  is  followed  by  recurrence, 
prolongs  life  on  an  average  about  fourteen  months. 

At  the  time  this  report  was  published  there  were  22  patients 
still  living  after  operation.  Of  these,  9  were  cases  of  gastro- 
enterostomy and  13  of  gastrectomy.  The  former  will,  of  course, 
prove  fatal  within  a  few  months.  So  far  as  the  latter  are  con- 
cerned, their  length  of  life  since  operation  is  shewn  in  the  follow- 
ing table : 

I  case    is     in  the  eighth    year  since  gastrectomy. 

1  case     "         "       fourth       "        "  " 

2  cases  are      "       third  "        "  " 

3  "       "        "        second      "        "  " 
6       "       "        "        first           "        "  " 


324  ABDOMINAL   OPERATIONS. 

Von  Mikulicz,  in  1901,  published  the  results  of  his  experience 
from  April,  1891,  to  March,  1901.  During  this  period  458  cases 
of  cancer  of  the  stomach  had  been  under  observation  in  the  clinic 
at  Breslau.  This  number  includes  46  cases  of  cancer  of  the 
cardia.  The  diagnosis  was  confirmed  either  at  the  operation, 
or  by  observation  of  the  progress  of  the  disease,  or  by  examina- 
tion after  death.  In  several  cases  of  cancer  of  the  cardia  the 
diagnosis  was  confirmed  by  cesophagoscopy  or  by  the  removal  and 
examination  of  a  small  portion  of  the  growth.  In  128  cases  no 
operation  was  performed,  chiefl}^  because  radical  removal  was  no 
longer  possible,  and  because  there  was  no  indication  for  any  pal- 
liative procedure,  such  as  gastro-enterostomy.  In  exceptional 
cases  the  operative  interference  was  declined  by  the  patient. 
The  total  duration  of  life  from  the  commencement  of  the  disease 
(as  inferred  from  the  symptoms  in  67  cases  in  which  it  was  possible 
to  ascertain  the  facts)  varied  from  a  few  months  to  38  months — 
an  average  of  iii  months. 

In  320  cases  recourse  was  had  to  operation  as  follows : 

1 .  Simple  exploratory  incision 44 

2 .  Gastrostomy  (in  cancer  of  cardia) 27 

3 .  Jejunostomy 12 

4.  Gastro-enterostomy 143 

5.  Resection  of  stomach 100 

6.  Extirpation  of  stomach 3 

Exploratory  Incision. — Four  deaths  followed  this  operation, 
giving  a  mortality  of  9  per  cent.  The  average  duration  of  life 
after  operation  was  4y^,j  months,  and  from  the  beginning  of  the 
disease,  i4y-o  months.  If  the  cases  submitted  to  exploratory 
laparotomy  be  added  to  those  in  which  no  operation  was  per- 
formed, we  get  an  average  duration  of  life  of  a  little  over  13 
months  from  the  beginning  of  the  disease,  a  figure  which  is 
adopted  by  the  author  as  a  basis  for  judging  of  the  results  of  the 
operative  treatment  of  gastric  cancer. 

Gastro-enterostomy.— There  were  48  deaths  in  143  cases — a 
mortality  of  33  ,'„  per  cent.  Although  during  the  last  three  years 
the  mortality  has  been  reduced  to  26^  per  cent.,  it  is  still  very 


CHOICE   OF   OPERATION    IN    CANCER   OF    STOMACH.  325 

high  in  proportion  to  the  same  operation  in  non-cancerous  con- 
ditions. The  average  duration  of  Hfe  after  operation  was  6y\ 
months,  and  from  the  beginning  of  the  disease,  14  months; 
but  if  the  operation  deaths  are  included,  this  is  reduced  to  T-2f-^ 
months,  slightly  shorter  than  the  duration  of  life  when  no  opera- 
tion is  performed. 

Resection  of  the  Stomach. — There  were  37  deaths  in  100 
cases.  In  the  last  three  years  the  death-rate  has  been  reduced  to 
25  per  cent. ;  that  is  to  say,  a  mortality  slightly  lower  than  that 
of  gastro-enterostomy.  The  results,  as  observed  in  58  patients 
who  survived  the  operation,  and  whose  subsequent  history  is 
known,  are  as  follows :  20  are  still  alive  between  6  months  and  8^ 
years : 

Longer  than   i      year,     17   are  alive.  » 

"  "     2      years,   10       "        " 

"  "     3i  years,     4       "        " 

These  last  four  may  be  regarded  as  radically  cured.  The  author 
regards  these  results  as  quite  as  good  as  those  after  operations 
for  cancer  of  the  tongue  or  rectum. 

It  will  thus  be  seen  that  there  is  no  great  divergence  in  the 
results  taken  from  the  two  clinics,  allowing  for  the  fact  that  the 
number  of  cases  in  the  one  is  almost  double  that  in  the  other, 
while  the  period  covered  by  the  observations  is  only  one-half. 
Kronlein  records  264  cases  extending  over  21  years ;  von  Mikulicz, 
458  in  10  years.     The  results  may  be  compared  in  this  way: 

Kronlein.       Mikulicz. 
Months.        Months. 

The  non-operated  cases  lived,  from  the  begin- 
ning of  the  disease 12J  iii 

The  cases  treated  by  exploratory  laparotomy .  .  13  i4to 

The  cases  treated  by  gastro-enterostomy 15  J  14 

The  cases  treated  by  gastrectomy 26^  24^ 

In  comparison  with  these  statistics  quoted  from  Mikulicz 
and  Kronlein  I  will  offer  those  given  by  W.  J.  Mayo  ("Jour. 
Amer.  Med.  Assoc,"  1910,  i,  1908),  which  may  be  taken  as  rep- 
resenting the  highest  modern  achievements.     In  the  Mayo  Clinic 


326  ABDOMINAL   OPERATIONS. 

from  April  21,  1907,  to  January  27,  1910,  the  cases  of  cancer  of 
the  stomach  treated  b}^  operation  are  arranged  as  follows: 

Total  number 627 

Explorations — hopeless  condition  found 206 

Gastro-jejunostomy  performed 169 

Gastrostomy 26 

Excision  of  ulcer  (cancerous  changes  being  found) 2 

Resection  for  cancer 224 

The  appended  details  of  the  cases  of  partial  gastrectomy  are 
given : 

TABLE    I.— OPERATIONS    FOR    Cx\RCINOMA   INVOLVING    THE 
PYLORIC    END  OF  THE  STOMACH 

Total  number 224 

Males 163 

Females 61 

Age  of  oldest 81 

Age  of  youngest 30 

Average  age 53 

Patiexts  Operated  on  Over  Five  Years  Ago. 

Total  number 50 

Present  condition  known 39 

Alive  and  well  (one  eight  years,  two  and  one-half  months;  one 
eight  years;  *one  seven  years,  two  months;    one  six  years      11 
eleven  months;  one  five  years,  three  and  one-half  months; 
one  five  years) 6 

Patients  Operated  Upon  Over  Four  Years  Ago. 

Total  number 85 

Present  condition  known 64 

Alive  and  well 13 

Patients  Operated  Upon  Over  Three  Years  Ago. 

Total  number 117 

Present  condition  known 88 

Alive  and  well 18 

Patients  Operated  Upon  Less  Than  Three  Years  Ago. 
Total  number 107 

Cases  in  the  last  group  (operations  less  than  three  years 
ago)  are  too  recent  to  be  of  any  statistical  value  as  to  the  question 
of  cure. 

A  careful  study  of  the  wealth  of  experience  laid  bare  in  these 
records  will  enable  us  more  clearly  to  formulate  our  ideas  as  to  the 

*Has  since  died  of  recurrence. 


CHOICE   OF   OPERATION   IN   CANCER   OF    STOMACH.  327 

principles  that  should  guide  us  in  dealing  with  this  most  serious 
disease.  In  the  first  place,  it  must  be  admitted  that  our  means 
of  obtaining  cases  sufficiently  early  are  almost  as  meagre  as  it  is 
possible  for  them  to  be.  Until  more  accurate  methods  of  diag- 
nosis are  established,  it  is  absolutely  imperative  that  recourse 
should  be  had  earlier  and  more  often  to  the  exploratory  laparot- 
omy. At  present  that  operation  is  limited  to  the  examination 
of  patients  when  the  diagnosis  has  been  made,  and  when  the  only 
question  to  be  settled  is  whether  or  not  the  growth  is  removable. 
But  in  order  to  better  our  results  we  must  explore,  not  to  confirm, 
but  to  make,  a  diagnosis. 

When  the  diagnosis  has  been  made  and  the  patient  is  sub- 
mitted to  operation,  it  is  difficult  to  decide  upon  the  exact  sur- 
gical procedure  which  it  is  wisest  to  adopt.  Von  Mikulicz, 
Kronlein,  and  not  a  few  other  surgeons  have  spoken  strongly 
upon  the  question  of  gastro-enterostomy,  saying  that  this  method 
should  be  adopted  only  in  cases  where  stenosis,  either  at  or  near 
the  pylorus,  is  caused,  or  in  cases  where  stasis  of  food  is  marked. 
There  can  be  no  doubt  that  in  such  cases  gastro-enterostomy  is 
productive  of  the  most  remarkable  benefit  to  the  health  and  well- 
being  of  the  patient.  The  weight  increases,  the  appetite  and  the 
power  of  gratifying  it  return,  and  vomiting,  often  the  most  dis- 
tressing and  unceasing  symptom,  stops  at  once.  But  there  can 
also  be  no  doubt  that  in  some  instances,  when  the  growth  does 
not  actually  obstruct,  by  its  bulk,  the  onward  passage  of  food,  a 
decided  benefit  results  from  the  operation.  The  stomach  is 
better  and  more  quickly  drained,  and,  as  a  rule,  food  can  be 
taken  more  frequently  and  with  greater  comfort.  In  the  ma- 
jority of  these  cases,  however,  little  or  no  benefit  results  from 
gastro-enterostomy.  The  position,  therefore,  may  be  thus 
briefly  stated:  If,  after  exploration,  a  growth  is  found  to  be  ob- 
structing the  pylorus  or  to  be  narrowing  the  stomach  and  caus- 
ing an  hour-glass  condition,  or  if  stasis  of  food  has  been  a  marked 
symptom,  then  gastro-enterostomy  will  give  very  decided  relief. 
If,  on  the  other  hand,  the  growth  be  confined  to  one  or  other 


328  ABDOMINAL   OPERATIONS. 

of  the  curvatures,  and  if  neither  stenosis  nor  stasis  be  present, 
gastro-enterostomy  wiU  give  Httle  or  no  relief:  it  will  not  pro- 
long life  nor  give  a  greater  degree  of  comfort. 

I  am  entirely  in  agreement  with  the  advice  given  by  the  man 
most  competent  to  express  it,  W.  J.  Mayo,  to  the  effect  that  gas- 
trectomy may  with  great  benefit  be  performed  not  only  as  a 
possibly  curative  operation,  but  also  deliberately  as  a  palliative 
operation  when  growths  are  present  in  inaccessible  glands  or  in 
the  liver. 

The  mortality  of  gastrectomy  has  been  so  much  reduced  by 
the  perfection  of  the  technique  of  the  operation  that  the  figures 
of  Kronlein  and  Mikulicz,  though  they  must  still  be  quoted,  do 
not  represent  the  best  practice  of  today.  Gastrectomy  does  not 
now  involve  a  greater  immediate  mortality  than  lo  per  cent.,  and 
the  relief  to  the  patient  from  the  removal  of  a  noxious  ulcerating 
mass  in  the  stomach  is  very  considerably  greater  than  that  which 
attends  gastro-enterostomy  alone. 

The  operation  of  gastrectomy  in  the  hands  of  von  Mikulicz 
and  of  Carle  and  Fantino  has  given  a  lower  mortality  than  gastro- 
enterostomy. Its  advantages  as  compared  with  gastro-enter- 
ostomy are  that  it  gives  a  greater  prolongation  of  life— ten  or 
eleven  months  longer — and  that  it  affords  a  greater  degree  of 
comfort  to  the  patient.  Though  recurrence  may  follow,  yet  in 
the  majority  of  cases  the  patient  is  relieved  greatly  by  the  re- 
moval of  a  foul,  ulcerating  growth,  from  the  surface  of  which  an 
offensive  and  septic  discharge  is  constantly  occurring,  and  from 
which  haemorrhages,  more  or  less  copious,  are  often  likely  to 
take  place.  If,  after  removal  of  a  malignant  growth  of  the 
stomach,  the  surgeon  will  open  the  viscus  and  inspect  the  sur- 
face of  the  tumour,  he  will  realise,  when  he  sees  the  foul,  ulcerous 
mass,  that  its  removal  cannot  but  be  of  vast  benefit  to  the  pa- 
tient. It  is  true  that  in  the  great  majority  of  cases  the  growth 
will  recur  either  locally  or  generally;  but  the  question  may 
arise  as  to  whether  gastrectomy  should  not  be  performed  de- 
liberately  as   a   palliative   operation   in    cases   where    an   early 


CHOICE  OF  OPERATION  IN  CANCER  OF  STOMACH.     329 

secondary  deposit  can  be  seen  in  the  liver,  or  inaccessible  or 
irremovable  glands  be  found  in  the  pancreas  or  along  the  aorta 
and  vena  cava.  If  we  take  into  account  the  following  ad- 
vantages of  gastrectomy  as  compared  with  gastro-enterostomy — 
that  in  the  most  competent  hands  its  mortality  is  not  greater, 
but  is  even  less,  than  the  mortality  of  gastro-enterostomy; 
that  a  prolongation  of  life  for  ten  months  longer  than  the  period 
given  by  gastro-enterostomy  is  the  rule;  that  the  comfort,  the 
general  health,  appetite,  and  well-being  of  the  patient  are  all 
emphatically  better;  and,  finally,  that  the  patient  has  always  a 
chance,  even  though  it  is  of  the  slenderest,  of  a  complete  re- 
covery from  his  disease — if  we  take  all  these  into  our  considera- 
tion, there  can  be  no  doubt  that  the  operation  of  choice  will 
always  be  gastrectomy.  Gastrectomy  will  be  done  always 
when  a  radical  operation  is  attempted :  it  will  probably  be  done 
often  when  nothing  more  than  a  palliative  operation  is  intended. 

If,  after  the  abdomen  has  been  opened,  it  is  found  impossible 
or  imprudent  to  attempt  either  gastro-enterostomy  or  gastrec- 
tomy, some  relief  may  be  obtained  by  performing  duodenos- 
tomy  or  jejunostomy.  The  scope  of  these  procedures  is  very 
strictly  limited;  but  in  rare  instances,  when  the  prolongation 
of  life  for  even  two  or  three  weeks  is  of  the  greatest  importance, 
then  either  of  these  operations  can  be  done  with  propriety.  The 
operations  are  simple,  speedily  done,  and  cause  little  or  no  shock, 
and  they  can,  if  need  be,  be  readily  performed  with  cocaine 
anaesthesia. 

In  Mural  Cancer.- — In  these  cases  obstruction  may  be  absent. 
Diagnosis  is,  therefore,  not  so  early,  so  that  when  the  abdomen 
is  opened  a  large  area  of  stomach  may  already  be  affected. 
Even  if  no  narrowing  is  produced,  a  gastro-enterostomy,  by 
determining  rest,  will  assuage  pain  and  lessen  the  rate  of  growth. 
A  complete  local  removal,  however,  is  the  ideal  for  whose  at- 
tainment we  should  strive. 

The  extent  of  such  removal  will  vary  from  the  minimum  of 
an  hour-glass  stomach  to  the  maximum  of  a  general  infiltration 


330  ABDOMINAL   OPERATIONS. 

of  both  walls.  The  surgeon  will  be  guided  in  a  decision  by  the 
extent  of  such  growth  and  by  his  personal  capacity  and  pref- 
erence. It  is,  I  think,  possibly  open  to  question  whether  a 
complete  gastrectomy  is  a  scientific  operation  or  a  brilliant  ex- 
ploit in  surgical  gv^mnastics.  The  records  of  the  cases  so  far 
performed  are  certainly  far  better  than  could  have  been  an- 
ticipated— one  case  of  my  own  did  ver^^  well  (see  next  chapter) . 

In  all  cases  of  local  excision,  whether  in  the  body  of  the  stom- 
ach or  at  the  pylorus,  a  wide  healthy  area  surrounding  the 
grovv1;h  should  be  removed.  Experience  goes  forcibly  to  shew 
that  it  is  from  local  recurrence  that  patients  die,  even  when  the 
incisions  have  been  made,  as  it  would  seem,  wide  of  the  disease. 
The  direction  of  the  spread  of  the  gro^^1:h  should  be  carefully 
noticed.  If  the  growth  is  spreading  circularly  in  the  line  of  the 
vessels,  it  shews  little  tendency  to  recur  after  removal;  if  it  is 
spreading  transversely  along  the  curvatures,  there  is  said  to  be 
a  strong  tendency  to  recurrence  (Mayo).  The  importance  of 
Cuneo's  observations,  already  referred  to,  may  be  again  em- 
phasised. 

In  Growth  at  the  Cardiac  End. — Only  palliative  operations  are 
possible  when  the  growth  involves  the  cardiac  orifice  and  the 
adjacent  portion  of  the  stomach.  Le\'y  has,  indeed,  planned  an 
operation — and  practised  it  upon  the  cadaver — for  the  purpose 
of  removing  such  a  gro\vth  ("  Langenbeck's  Archiv,"  1898),  but, 
so  far  as  we  know,  a  procedure  of  this  kind  has  only  once  been 
attempted  during  life.  This  was  by  Mikulicz,  who  removed  a 
primary  carcinoma  of  the  cardia  and  a  portion  of  the  oesophagus 
between  3  and  4  cm.  in  length.  The  operation  was  exceedingly 
difficult  on  account  of  spreading  of  the  growth  towards  the  pan- 
creas and  implication  of  the  retroperitoneal  lymphatic  glands. 
The  patient  died  of  peritonitis.  Mikulicz  expresses  the  hope  that 
not  only  carcinoma  of  the  cardia,  but  even  of  the  lower  end  of  the 
oesophagus,  may  soon  prove  to  be  within  the  safe  reach  of  a  capa- 
ble surgeon. 


CHOICE   OF   OPEILA.TION   IN   CANCER   OF    STOMACH.  33 1 

Krehl  has  shewn  that  in  dogs  the  two  pneumogastrics  may  be 
completely  destroyed  at  the  lower  end  of  the  oesophagus  without 
interfering  in  any  degree  with  the  processes  of  digestion. 

In  all  cases  gastrostomy  should  be  performed  at  the  earliest 
moment  after  the  diagnosis  is  assured. 
^ 


CHAPTER  XVII. 

COMPLETE  GASTRECTOMY. 

The  following  are  the  notes  of  a  case  in  which  I  removed 
the  whole  stomach  on  account  of  its  universal  implication  in 
a  malignant  growth. 

The  patient,  a  married  man,  aged  forty-three  years,  who  had 
been  under  the  care  of  Dr.  Peter  Macdonald  of  Acomb,  was  ad- 
mitted to  the  Leeds  General  Infirmary  on  May  24,  1907.  He  was 
the  father  of  two  healthy  children  and  had  always  been  healthy 
himself,  the  only  illnesses  which  he  could  remember  being 
influenza  two  or  three  times  and  an  ischiorectal  abscess  some  ten 
years  previously  to  admission.  He  had  always  had  as  his  occu- 
pation the  management  of  horses  and  had  been  in  his  present  situ- 
ation as  coachman  for  five  years.  He  said  that  all  his  relatives, 
so  far  as  he  could  remember,  had  died  from  "old  age. "  He  had 
been  in  good  health  up  to  two  years  ago  when  he  gradually  began 
"to  go  off  his  food. "  By  this  he  meant  that  he  did  not  want  his 
food  quite  as  he  had  been  accustomed  to  do.  He  could  eat  any- 
thing but  was  afraid  of  the  pain  which  he  knew  would  come  on 
after  taking  anything.  This  pain,  which  was  relieved  by  food 
for  an  hour  or  so,  was  situated  in  the  epigastrium  and  continued 
until  he  vomited,  when  it  at  once  subsided  until  an  hour  after  his 
next  meal.  The  kind  of  food  taken  made  no  difference  to  the 
pain  experienced.  The  vomiting  commenced  as  a  profuse  gush, 
and  in  the  vomit  he  recognised  food  which  he  had  taken  at  his 
last  meal.  There  was  never  to  his  knowledge  any  haematemesis. 
After  the  first  six  months  he  was  free  for  some  weeks  from  pain 
and  vomiting,  but  at  this  time  he  was  under  medical  supervi- 
sion and  was  taking  liquids  chiefly ;  he  had  his  stomach  washed 
out  ever}'  other  day  for  two  weeks  and  was  away  from  work  for 
eight  weeks.  The  stomach  contents  at  this  time  were  analysed 
as  there  was  a  suspicion  of  cancer  in  the  medical  attendant's  mind; 
but  the  analysis  gave  a  normal  result.  After  eight  weeks  he  re- 
turned to  work  still  taking  fluids  and  feeling  much  better,  but 


COMPLETE   GASTRECTOMY. 


333 


every  now  and  again  he  had  attacks  of  vomiting  and  pain;  he 
noticed  that  he  began  to  feel  the  pain  at  shorter  intervals  after 
his  food  was  taken,  but  he  was  still  relieved  by  vomiting.  All 
this  time  he  was  steadily  losing  weight,  which  had  fallen  from  1 1 
stones  4  pounds  to  less  than  9  stones.  He  had  also  noticed  that 
the  amount  of  fluid  taken  at  any  one  period  was  much  less  than 
formerly,  until  last  Christmas,  when  the  amount  was  so  dimin- 
ished that  he  was  only  able  to  take  three  or  four  mouthfuls  at  a 
time  before  he  experienced  a  feeling  of  discomfort  and  vomited. 


Fio-.  122. — View  of  the  stomach  from  the  outside. 


From  that  time  to  the  time  of  his  admission  this  diminution  in 
amount  continued. 

On  admission  the  patient  was  in  fairly  good  condition,  but 
he  looked  as  though  he  had  been  a  stouter  man  at  some  time, 
his  skin  was  somewhat  loose,  his  muscles  were  flabby,  and  his 
cheeks  were  a  little  hollowed.  His  weight  was  8  stones  2  pounds. 
When  he  was  given  some  fluid  to  drink  he  merely  sipped  it  a 
mouthful  at  a  time  and  had  to  wait  a  few  seconds  (about  ten  sec- 
onds) before  the  fluid  ' '  settled ' ' — he  gulped  and  strained  his  neck 
forward  as  though  trying  to  get  the  liquid  to  pass  an  obstruction. 
After  a  few  seconds  he  would  appear  comfortable  and  ready  for 


334 


ABDOMINAL   OPER.\TIONS. 


another  mouthful.  He  still  vomited  occasionally — the  vomit 
was  not  fermented  or  sour.  He  could  not  take  any  solid  food  at 
all  with  the  exception  of  cheese,  a  few  "nibbles"  of  which  he  en- 
joyed. He  never  had  any  desire  for  food;  in  all  about  from  30 
to  40  ounces  of  fluid  were  taken  daily. 

Abdominal  examination. — The  abdomen  looked  thin  and 
excavated ;  its  anterior  surface  receded  sharply  from  the  raised 
costal  margin.  Palpation  revealed  nothing  abnormal;  the  walls 
were  rigid  and  nothing  unusual  could  be  felt  through  them.     Two 


Fig.    123. — The  stomach  laid  open. 


very  small  doses  of  tartaric  acid  and  bicarbonate  of  sodium  were 
given  separately.  Instantly  some  foam  gushed  out  of  the  mouth. 
On  examining  the  abdomen  a  puffy  swelling  of  about  the  size  of  a 
billiard  ball  was  seen  and  felt  in  the  left  upper  half  of  the  epigas- 
trium immediately  below  the  costal  margin.  No  other  part  of 
the  stomach  was  distended,  and  the  inflated  portion  was  every- 
where quite  definitely  circumscribed.  The  conclusion  reached 
from  this  examination  was  that  there  was  possibly  an  hour-glass 
stomach  with  a  very  small  cardiac  complement,  and  that  this 


COMPLETE    GASTRECTOMY. 


335 


was  due  to  the  cicatricial  contraction  of  an  ulcer  on  the  lesser 
curvature  close  to  the  cardia.  A  stomach-tube  was  then  passed. 
It  went  17  inches  quite  readily,  but  not  further  than  that.  Only  a 
small  quantity  of  fluid  could  be  introduced.  A  little  over  four 
ounces  was  the  most  that  could  be  retained ;  when  this  had  flowed 
into  the  stomach  the  patient  began  to  complain  of  pain,  great 
tightness  and  oppression,  and  was  obviously  greatly  distressed. 
The  fluid  soon  returned  clear ;  on  one  occasion  a  little  blood  was 
seen.  Bile  was  frequently  seen  in  the  washings.  At  one  exam- 
ination it  was  found  that  when  a  measured  quantity  of  fluid  was 


Fig.  124. — Skiagram  of  the  stomach  filled  with  bismuth.      X  and  X  are  placed 
opposite  the  cardiac  and  pyloric  constrictions. 


used  for  the  washing  only  two-thirds  of  it  was  returned  through 
the  tube.  On  two  subsequent  occasions  the  stomach  was  inflated ; 
on  one  the  swelling  at  the  cardiac  end  was  again  well  seen;  on 
another  it  could  not  be  demonstrated.  The  following  was  the 
result  of  an  examination  of  a  test-meal.  Macroscopic :  Food 
badly  digested;  blood.  Chemical:  Blood;  no  free  hydrochloric 
acid ;  no  lactic  acid.  Microscopic :  Yeast  present ;  sarcinse  pres- 
ent ;  bacillus  geniculatus  present  and  other  organisms  numerous ; 
pus  abundant. 

The  diagnosis  was  made  of  hour-glass  stomach  with  a  ver>^ 
small  cardiac  complement.     Owing  to  the  impossibility  of  in- 


336 


ABDOMINAL   OPERATIONS. 


flating  the  distal  or  pyloric  part  of  the  stomach,  reference  was 
made,  when  the  case  was  demonstrated  to  the  ward-class,  to  the 


Fijr.   125. — The   stomach  freed  from   both   omenta   and   attached   only  by   the 

oesophagus. 


possibihty  of  its  being  an  example  of  "leather-bottle "  stomach,  the 
"linitis  plastica"  of  Brinton. 


COMPLETE    GASTRECTOMY, 


337 


Operation  was  advised  and  was  performed  on  May  31st  in 
the  following  manner:    The  abdomen  was  opened  in  the  middle 


Fig.  126. — A  loop  of  the  jejunum  has  been  pulled  upwards  through  an  open- 
ing in  the  transverse  mesocolon  and  a  layer  of  sutures  unites  it  to  the  oesophagus. 
The  stomach  is  used  as  a  tractor. 

line  by  an  incision  which  at  first  was  about  three  inches  in  length, 
sufficient  to  allow  of  exploration,  but  which  was  increased  subse- 

VOL.  I — 22 


338  ABDOMINAL  OPERATIONS. 

quently  to  a  length  of  eight  inches.  At  the  outset  there  was  a 
ver}^  serious  difficulty  in  exposing  the  stomach.  The  patient  was 
a  man  who  had  been  stout  but  who  had  lost  weight  rapidly ;  the 
anterior  abdominal  wall  therefore  shelved  downwards  from  the 
elevated  costal  margin  in  such  manner  as  to  make  the  upper  part 
of  the  stomach  appear  to  be  at  great  depth  from  the  surface. 
The  patient,  moreover,  was  not  at  all  comfortable  under  the 
anaesthetic  and  I  had  to  w^ait  a  long  time  after  opening  the  ab- 
domen before  I  could  proceed  with  the  operation. 

When  the  stomach  was  exposed  it  was  seen  to  be  small  in 
size  with  walls  of  great  thickness  and  sohdity.  The  whole  organ, 
indeed,  felt  solid,  resembling  a  very  large  uterus,  having  thick 
walls  and  an  insignificant  cavity  within  it.  (This  is  well  shewn 
in  the  skiagraph  subsequently  taken.)  The  surface  was  smooth, 
white,  and  opaque ;  there  were  no  adhesions  and  but  few  obviously 
enlarged  glands  along  the  curvatures.  Towards  the  cardiac  end 
the  stomach  was  larger  than  elsewhere,  so  that  the  organ  had 
something  of  the  shape  of  a  Florence  flask ;  the  larger  part,  how- 
ever, was  still  very  much  smaller  than  the  normal.  This  being 
the  condition  of  the  stomach  it  was  at  once  evident  that  the  per- 
formance of  gastro-enterostomy  was  impossible,  for  there  was  no 
sufficient  cavit}^  in  the  stomach  to  admit  of  any  anastomosis 
being  made.  The  alternative  procedures  were  complete  gas- 
trectomy^ and  either  jejimostom}^  or  duodenostomy ;  after  some 
dehberation  I  decided  in  favour  of  the  former  and  I  proceeded  at 
once  to  remove  the  whole  stomach.  It  was  at  this  point  that  the 
abdominal  incision  was  enlarged.  Hot  moist  swabs  in  two  lay- 
ers were  then  packed  into  the  abdomen  in  the  usual  manner  to 
isolate  the  field  of  operation.  The  stomach  was  now  depressed 
as  far  as  possible  b}^  forcible  traction  by  an  assistant,  and  two 
long  cHps  were  applied  to  the  coronary  artery  at  its  origin  from 
the  coeliac  axis.  The  artery  was  divided  between  the  clips  and 
its  proximal  end  was  ligatured.  The  upper  and  lower  coronary 
groups  of  glands  were  detached  downwards  towards  the  stomach 
by  gauze  stripping  and  the  cardiac  end  of  the  stomach  was  de- 
nuded by  the  same  means.  The  gastrohepatic  omentum  was 
divided  after  ligature  as  close  up  to  the  liver  as  possible  until  the 
upper  border  of  the  pylorus  was  reached.  Here,  by  gauze  strip- 
ping, the  pyloric  artery  and  the  gastroduodenal  artery  were  ex- 
posed as  they  separately  arose  from  the  main  hepatic  trunk. 


COMPLETE   GASTRECTOMY. 


339 


The  pyloric  artery  was  ligatured  and  divided  and  the  finger 
was  then  passed  downwards  behind  the  pylorus  and  made  to  pre- 


Fig.  127. — Lines  of  incision  into  oesophagus  and  jejunum. 

sent  at  the  lower  border  of  the  duodenum,  where  an  opening  was 
made  in  the  great  omentum.  Through  this  opening  the  blade  of  a 
clamp  was  passed  upwards  behind  the  duodenum  to  present  above 


340  ABDOMINAL   OPERATIONS. 

the  pylorus.  When  this  clamp  was  closed  it  lay  about  one  inch 
be^^ond  the  pylorus  and  on  the  stomach  side  of  it  there  lay  the 
subpyloric  group  of  glands.  A  second  clamp  with  rubber-covered 
blades  was  now  applied  distal  to  it  and  the  duodenum  was  cut 
between  them.  A  single  strong  catgut  suture  was  then  passed 
through  the  proximal  part  of  the  duodenum  and  round  the  clamp 
to  prevent  the  clamp  from  slipping  away.  The  distal  end  of  the 
duodenum  was  then  closed  b}'  a  continuous  catgut  suture,  taking 
all  the  coats,  and  by  a  double  la^^er  of  Pagenstecher  thread  suture 
above  this.  The  clamp  holding  the  proximal  part  of  the  duo- 
denum was  now  covered  with  a  gauze  swab  and  was  lifted  well  to- 
wards the  left,  exposing  the  gastroduodenal  artery  more  con- 
spicuously. The  artery  was  ligatured  and  divided.  Along  the 
whole  length  of  the  greater  curvature  the  gastrohepatic  omen- 
tum was  divided  at  a  distance  from  the  stomach  of  from  i  to  2 
inches,  so  that  all  glands,  including  one  or  two  dropped  glands, 
were  left  attached  to  the  stomach.  The  whole  stomach  was  now 
free,  for  the  gastrohepatic  omentum  had  been  entirely  divided, 
the  duodenum  was  severed,  and  the  gastrocolic  omentum  lig- 
atured and  cut  free.  The  whole  stomach  hung  pendulous  from 
the  oesophagus.  At  this  point  the  anesthetist  was  asked  to  flex 
the  patient's  neck  as  much  as  possible,  in  the  hope  that  this 
might  enable  the  oesophagus  to  be  pulled  downwards  a  little  more 
readily,  and  it  seemed  that  this  hope  was  fulfilled.  The  oesopha- 
gus was  dragged  upon  with  a  fair  degree  of  force  until  at  least 
three-quarters  of  an  inch  of  it  was  visible  below  the  diaphragm. 
The  next  step,  and  the  most  important  and  difficult  of  all, 
was  the  anastomosis  of  the  oesophagus  to  the  jejunum.  The 
transverse  mesocolon  was  already  exposed  on  its  upper  surface 
in  the  wound ;  it  was  divided  in  an  avascular  area  and  the  upper 
loop  of  the  jejunum  pulled  through  it.  A  point  on  this  about 
eight  inches  from  the  duodenal- jejunal  flexure  was  selected  for 
the  anastomosis.  A  piece  of  it  about  two  and  a  half  inches  in 
length  was  laid  transversely  along  a  line  immediately  behind  the 
oesophagus.  As  it  lay  there  transversely,  the  right  leaf  posterior, 
its  upper  end  was  to  the  left,  its  lower  to  the  right.  The  anas- 
tomosis was  now  begun  by  introducing  eight  light  interrupted 
sutures  between  this  portion  of  the  jejunum  and  the  oesophagus. 
The  part  of  the  circumference  of  the  jejunum  used  was. that  on 
the  surface  which  was  now  posterior  and  on  this  surface  about 


COMPLETE    GASTRECTOMY. 


341 


three-quarters  of  an  inch  from  the  mesenteric  attachment.  As 
the  sutures  were  introduced  into  the  oesophagus  this  was  made 
to  present  and  was  well  exposed  by  a  forcible  and  continuous 
downward  traction  upon  the  stomach.  The  stomach,  wrapped 
in  a  hot  gauze  swab,  was  used,  and  most  efficiently  used,  as  a  re- 
tractor, or  rather  as  an  instrument  of  traction,  upon  the  shghtly 
dilated  oesophagus.  The  help  derived  from  this  manoeuvre  was 
far  greater  than  could  be  believed  from  a  mere  description.  It 
converted  what  would  have  been  an  excessively  difficult  feat  into 


Fio-.  128. — Suture  of  margins  of  openings  in  oesophagus  and  jejunum. 


one  of  comparatively  easy  accomplishment.  Eight  interrupted 
sutures  then  were  introduced  until  the  whole  of  the  posterior 
half  of  the  oesophagus  was  securely  attached  to  the  jejunum.  In 
front  of  these  a  continuous  suture  was  now  introduced,  exactly 
as  in  the  operation  of  gastro-enterostomy  from  left  to  right ;  the 
needle  carrying  this  suture  was  then  laid  aside  to  be  presently 
resumed.  The  attachment  of  the  oesophagus  to  the  jejunum 
seemed  now  quite  secure  on  this  posterior  aspect.  In  front  of 
this  continuous  suture  a  small  opening  was  made  into  the  oesopha- 
gus and  into  the  jejunum  at  the  extreme  left  end  of  this  attach- 


342 


ABDOMINAL   OPERATIONS. 


ment.  A  continuous  through-and- through  Pagenstecher  thread 
suture  was  now  began  and  a  few  turns  of  the  needle  taken  until 
the  whole  length  of  the  small  openings  made  had  been  united. 
These  openings  were  then  enlarged  little  by  little  from  left  to 
right,  and  as  they  were  enlarged  their  cut  edges  were  sutured  by 
the  same  continuous  stitch.  This  sequence  of  a  small  incision,  a 
few  stitches,  slight  enlargement  of  the  incision,  a  few  more 
stitches,  was  continued  until  the  whole  of  the  posterior  part  of 
the  oesophagus  was  divided  and  sutured  to  the  incision  in  the 
jejunum.     Around  the  anterior  wall  of  the  oesophagus  the  same 


Fig.  1 29. — Suturing  almost  complete.      The  stomach  still  used  as  tractor. 

sequence  was  continued,  the  stitch  being  now  changed  to  the 
"loop  on  the  mucosa"  form.  The  result  was  that  the  stomach 
was  retained  as  a  tractor,  drawing  down  the  oesophagus  until  the 
last  piece  was  severed,  and  at  that  moment  the  line  of  anastomosis 
was  almost  complete.  Finally  the  outer  continuous  suture  pre- 
viously laid  aside  was  resumed  and  continued  round  the  anterior 
surface  of  the  oesophagus  and  jejunum  to  its  starting  point  where 
it  was  tied  and  cut  short.  The  suture  line  was  now  complete. 
There  were,  it  will  be  seen,  eight  interrupted  posterior  sutures, 
intended  as  anchor  sutures,  and  the  two  continuous  sutures,  as 
in  the  usual  operation  of  gastro-enterostomy.     A  few  anterior 


COMPLETE    GASTRECTOMY.  343 

anchor  sutures  fixing  the  jejunum  and  the  oesophagus  to  the  dia- 
phragm were  now  taken  and  the  main  part  of  the  operation  was 
now  complete.  The  great  omentum  was  turned  upwards  over 
the  operation  area  and  the  abdomen  closed. 

The  patient  had  borne  the  operation  well.  There  had  been 
no  soiling  of  the  operation  field  nor  any  exposure  of  viscera.  As 
soon  as  the  patient  was  put  back  to  bed  the  continuous  adminis- 
tration of  saline  fluid  by  the  rectum  was  commenced.  In  the 
first  twenty-four  hours  nine  pints  were  taken;  in  the  second 
twenty-four  hours,  six  pints.  After  this  it  was  discontinued. 
The  help  given  by  the  absorption  of  1 5  pints  of  normal  saline  solu- 
tion within  forty-eight  hours  is  probably  difficult  to  exaggerate. 
During  this  time,  contrary  to  my  usual  practice,  I  gave  no  fluid 
by  the  mouth,  but  the  patient  was  allowed  to  flush  his  mouth 
as  often  as  he  wished.  He  never  complained  of  thirst  and  did 
not  suffer  any  great  amount  of  pain.  He  was  kept  lying  flat  on 
his  back,  with  the  head  propped  well  forward.  The  administra- 
tion of  fluids  by  the  mouth  was  begun  very  cautiously  on  the  third 
day.  Two  teaspoonfuls  of  water  were  given  every  half-hour; 
on  the  fourth  day  this  quantity  was  increased  to  two  ounces  every 
half  hour.  On  the  fifth  day  five  ounces  were  given  hourly; 
water  and  peptonised  milk  and  albumin  water  were  given  in  suc- 
cession. On  the  sixth  day  two  pints  of  these  fluids  were  taken 
while  the  day  nurse  was  on  duty  and  one  pint  six  ounces  during 
the  night.  These  quantities  of  the  same  fluids  were  slowly  in- 
creased until  on  the  tenth  day  five  pints  were  taken  in  the  twenty- 
four  hours.  On  the  eleventh  day  beef-tea  and  Benger's  food  were 
given,  on  the  fourteenth  day  milk  pudding,  and  on  the  eighteenth 
day  bread  and  butter.  During  the  third  week  the  patient  told 
us  every  day  that  he  was  hungry,  a  sensation  which  he  had  not 
experienced  so  keenly  for  two  years.  At  the  end  of  the  third 
week  he  began  to  take  meals  of  fair  quantity  consisting  of  minced 
chicken,  milk  puddings,  etc.  He  was  kept  in  bed  for  eighteen 
days,  and  on  the  twenty-second  day  was  sent  to  a  convalescent 
hospital.  On  leaving  the  hospital  his  weight  was  8  stones  12 
pounds,  a  gain  of  10  pounds.  On  August  21st  he  weighed  10 
stones  and  was  able  to  eat  all  foods. 

This  is  the  second  occasion  upon  which  I  have  been  called* 
upon   to   perform    complete    gastrectomy.     The    circumstances 

*  "Brit.  Med.  Jour.,"  1903,  vol.  ii.,  p.  149S. 


344  ABDOMINAL   OPERATIONS. 

present  in  the  two  cases  were  similar;  the  stomach  was  small, 
with  thickened  w^alls  and  a  cavity  greatly  reduced  in  size ;  it  was 
invaded  in  every  part  by  cancer,  the  glands  were  only  slightly 
affected,  there  were  few  adhesions,  no  invasion  of  the  parts 
around  by  the  growth,  and  no  secondary  deposits.  It  has  been 
computed  by  Fenwick*  that  14  per  cent,  of  all  patients  dying 
from  carcinoma  of  the  stomach  shew  no  extension  of  the  disease 
bcA^ond  the  stomach.  The  type  of  cancer  in  both  these  patients 
was  atrophic  and  the  malignancy  was  probably  of  a  low  grade. 
It  would  seem  that  conditions  of  the  kind  enumerated  are  essen- 
tial to  the  successful  carrying  out  of  the  operation  of  complete 
gastrectomy.  In  my  first  case,  which  proved  fatal,  I  adopted  a 
technique  w^hich  I  thought  satisfactory.  After  the  operation  I 
gave  much  thought  to  the  details  of  the  operation  and  endeavoured 
to  construct  a  method  which  I  should  carry  out  if  the  opportunity 
again  came  to  me.  I  had  determined  to  make  use  of  the  stomach- 
tube  passed  through  the  oesophagus  into  the  jejunum  as  a  sort 
of  cylinder  upon  which  to  suture,  and  I  considered  that  the  fixa- 
tion (by  a  catgut  suture)  of  the  tube  to  the  cut  end  of  both 
oesophagus  and  jejunum  (the  suture  being,  of  course,  buried  by 
the  continuous  sutures  along  the  line  of  anastomosis)  would  help 
to  make  the  feeding  of  the  patient  during  the  time  of  healing  of 
the  wound  a  simple  and  a  safe  matter.  But  when  I  came  to  per- 
form this  second  operation  I  realised  as  I  saw  the  stomach  pen- 
dulous from  the  oesophagus  that  it  might  be  used  with  the  very 
greatest  advantage  to  hold  the  oesophagus  in  a  fixed  position 
until  my  suture  lines  were  practically  complete.  I  feel  sure  that 
this  point  is  one  which  has  solved  the  greatest  of  all  difficulties 
in  the  operation  of  complete  gastrectomy,  and  it  embodies, 
moreover,  a  technical  principle  which  is  applicable  to  other  op- 
erations than  this. 

Pathological  Report  by  Dr.  Craven  Moore. — The  specimen  in- 
cludes the  whole  stomach  and  about  a  quarter  of  an  inch  each  of 
the  oesophagus  and  duodenum.  The  stomach  is  greatly  dim- 
inished in  size,  its  length  being  four  and  a  quarter  inches,  and  its 
maximum  diameter  in  the  region  of  the  fundus  two  and  a  half 
inches.  In  form  it  is  tubular,  gradually  contracting  towards  the 
pylorus,  and  about  the  middle  third  it  presents  several  deep  trans- 
verse folds  which  it  is  impossible  to  obliterate  by  tension ;  in  con- 

*  "Cancer  of  Stomach,"  p.  54. 


COMPLETE    GASTRECTOMY. 


345 


sistency  it  is  firm  and  elastic.  Attached  to  the  stomach  are 
portions  of  the  gastro-hepatic  and  the  gastro-cohc  omenta,  and 
in  the  former  are  several  lymphatic  glands  which  are  firm  and  of 
normal  size;  the  omenta  themselves  appear  quite  normal.  The 
serous  coat  of  the  stomach  over  the  fundus  and  middle  third  of 
the  organ  appears  somewhat  thickened  and  more  opaque,  and 
here  and  there  presents  small  white  nodules  about  a  pin's  headin 


Cut  end  of  duodenum  closed 


Oesophagus 


Anastomosis 
with  jejunum 


Fig.  130. — Post-mortem  appearances  three  years  and  nine  months  later. 


size.  The  wall  of  the  stomach  is  greatly  thickened  and  indurated, 
the  thickening  being  greater  in  the  proximal  two-thirds  of  the 
organ,  where  it  measures  half  an  inch,  than  in  the  pyloric  portion, 
where  it  measures  a  quarter  of  an  inch.  The  cut  surface  of  the 
wall  shews  a  mucous  layer  rather  thinner  than  normal  lying  on  a 
much  thickened,  greyish-white,  dense  submucous  coat,  a  well- 
developed  muscular  coat  in  which  the  individual  fasciculi  are 
rendered  more  than  usually  evident  in  many  places  by  an  in- 


346  ABDOMINAL  OPERATIONS. 

crease  in  the  intermuscular  connective  tissue,  and  a  subserous 
and  a  serous  coat  which  also  appear  to  be  slightly  thickened. 

It  is  very  obvious  that  the  great  thickness  of  the  stomach 
wall  is  the  result  chiefly  of  the  increased  extent  of  the  submucous 
coat.  The  cavity  of  the  organ,  greatly  diminished  in  extent,  is 
divided  into  two  distinct  loculi  by  a  zone  of  contraction  situated 
in  the  middle  region  of  the  stomach,  where  the  cavity  is  reduced 
to  a  narrow  passage  a  quarter  of  an  inch  in  diameter;  this  zone 
of  contraction  corresponds  to  the  deep  folds  marking  the  external 
surface  of  the  organ.  The  cardiac  loculus  corresponding  to  the 
fundus  has  a  diameter  of  one  and  a  quarter  inches ;  it  is  rounded 
in  form  and  its  mucous  lining  has  a  mammillated  appearance. 
The  pyloric  loculus,  of  more  tubular  form,  is  divisible  into  two 
portions  by  the  character  of  its  mucosa:  in  the  proximal  portion, 
corresponding  to  the  middle  third  of  the  stomach,  the  mucous  lin- 
ing is  smooth  and  thinner  than  normal;  in  the  distal  portion, 
which  apparently  corresponds  to  the  pyloric  antrum,  the  mucous 
lining  is  of  normal  thickness  and  is  thrown  into  a  series  of  irregular 
folds ;  it  is  in  this  portion  of  the  organ  that  the  submucous  coat 
shews  the  least  change.  The  two  orifices  of  the  stomach  shew 
no  indications  of  contraction  and  the  stomach  wall  is  here  of 
normal  thickness. 

Microscopical  Examination. — Sections  of  the  wall  of  the  card- 
iac loculus  shew  a  thin  mucous  layer  in  which  only  the  deeper 
parts  of  the  tubules  are  present,  and  these  present  extensive  and 
irregular  proliferation  of  their  cells,  strands  of  which  can  be 
traced  down  into  the  underlying  submucosa ;  between  these  pro- 
liferous elements,  and  in  which  they  appear  to  be  embedded,  there 
is  granulation  tissue.  The  submucous  coat  consists  of  a  dense 
white  fibrous  tissue  in  which  the  fasciculi  of  fibrils  are  well  de- 
fined, run  more  or  less  parallel,  have  a  wavy  oblique  course,  and 
resemble  very  closely  the  fibrous  elements  seen  in  dense  fibromata 
and  in  the  atrophic  variety  of  scirrhous  carcinomata.  Towards 
the  mucous  layer  this  coat  is  sharply  defined;  on  the  other  side 
it  penetrates  the  muscular  coat  by  a  series  of  strands  running 
between  the  muscular  bundles.  This  dense  fibrous  tissue  shews 
a  great  paucity  in  cells,  but  in  its  innermost  layers  it  shews  here 
and  there  small  collections  and  strands  of  epithelial  cells,  man^^ 
of  which  can  be  seen  to  be  directly  continuous  with  similar  cells 
in  the  mucosa;   and  in  the  remainder  of  its  extent,  even  where  it 


COMPLETE    GASTRECTOMY.  347 

penetrates  between  the  bundles  of  the  muscular  coat,  there  are 
to  be  seen  isolated  strands  and  small  islands  of  similar  cells  be- 
tween the  white  fibres,  the  latter  in  particular  being  commonly 
adjacent  to  some  blood-vessel  and  accompanied  by  a  number  of 
leukocytes.  The  blood-vessels  are  few  in  number  and  shew  some 
thickening  of  their  external  coats  but  no  obvious  change  in  their 
middle  or  internal  coats.  The  muscular  coat  does  not  appear  to 
be  increased  in  thickness;  the  muscular  bundles  are  separated 
by  strands  of  dense  fibrous  tissue  penetrating  it  from  the  sub- 
mucosa,  which  become  more  and  more  attenuated  in  the  outer 
layers  and  so  disappear ;  the  muscle  cells  here  and  there  shew  in- 
dications of  hyaline  transformation  but  otherwise  are  normal. 
The  subserous  coat  is  slightly  thickened  and  very  occasionally 
one  sees  a  few  epithelial-like  cells.  The  serosa  appeared  normal. 
Sections  taken  from  the  zone  of  contraction  present  similar 
changes,  the  mucosa  is  even  thinner,  and  the  folding  of  the  stom- 
ach wall  is  seen  to  be  due  to  contraction  of  the  fibrous  submucosa. 
Sections  from  the  pyloric  portion  present  appearances  very  little 
removed  from  those  of  the  normal  organ.  Sections  of  the  lym- 
phatic glands  from  the  gastro-hepatic  omentum  .shew  here  and 
there  small  collections  of  cells,  very  similar  to  those  described  in 
the  submucous  coat,  situated  in  the  trabeculae  and  in  the  peri- 
vascular lymphatics. 

Attempting  to  interpret  these  appearances  there  can  be  no 
doubt  that  we  have  to  do  with  an  extensive  fibrous  hyperplasia 
commencing  in,  and  chiefly  limited  to,  the  submucous  coat  and 
involving  that  coat  almost  exclusively  in  its  proximal  two-thirds, 
a  condition  which  so  far  corresponds  with  Brinton's  conception 
of  plastic  linitis.  The  presence  of  the  scanty  proliferous  epithelial 
elements  in  the  remains  of  the  mucosa  and  in  the  midst  of  the 
new  formed  fibrous  tissue  of  the  submucosa  demonstrates  that 
the  lesion  is  not  merely  an  infiammatory  one  in  this  case  but  that 
it  is  essentially  a  neoplastic  change  of  a  particular  type  which  has 
its  analogue  in  the  so-called  atrophic  scirrhus  met  with  in  the 
mammary  gland. 

The  patient  made  a  good  recovery  from  the  operation.  He 
was  shewn  at  a  meeting  of  the  Section  of  Surgery  of  the  Royal 
Society  of  Medicine  on  December  19,  1907;  and  in  July,  1910, 
he  was  seen  and  examined  by  the  members  of  the  American  So- 
ciety of  Clinical  Surgery  who  were  than  in  Leeds.     He  died  on 


348  ABDOMINAL   OPERATIONS. 

January  31,  1911.  During  the  three  years  and  eight  months 
that  he  Hved  after  the  operation  he  was  under  the  constant  ob- 
servation and  the  occasional  care  of  Dr.  Geoffrey  Thompson,  of 
Scarborough,  who  has  kindly  given  me  very  full  details  of  his 
progress. 

The  patient  was  perfectly  well  up  to  the  early  part  of  the 
year  1910,  when  he  began  to  shew  the  evidences  of  a  profound 
anaemia.  He  was  strikingly  pale  and  breathless,  and  he  lost 
weight.  Under  treatment,  however,  he  improved,  and  in  May, 
1910,  his  colour  had  returned  and  he  was  able  to  ride  and  drive 
and  attend  to  matters  on  the  farm.  In  August,  1910,  he  began 
to  fail  again ;  he  became  easily  tired,  though  he  still  tried  to  carry 
out  the  greater  part  of  his  work.  His  appetite  remained  good 
and  he  had  no  indigestion.  In  October  the  signs  of  anaemia  re- 
appeared, he  grew  much  weaker,  and  had  to  cease  work.  He  be- 
gan again  to  lose  weight,  his  appetite  vanished,  and  he  occasion- 
ally vomited.  There  were  no  abnormal  physical  signs  of  any 
kind  in  the  chest  or  abdomen  throughout  the  illness.  Soon  after 
Christmas,  1910,  he  had  to  take  to  his  bed,  and  he  died  on  the 
last  day  of  January,  191 1. 

I  saw  the  man  myself  on  many  occasions.  He  expressed  him- 
self as  feeling  well  and  vigorous,  and  he  had  gained  2  stones  10 
pounds  after  the  operation,  and  he  held  the  gain  for  nearly  three 
years.  His  appetite  was  good,  he  experienced  the  sensation  of 
hunger,  and  he  was  able  to  eat  the  ordinary  foods ;  but  he  had  to 
take  a  rather  longer  time  over  a  meal  than  in  the  days  preceding 
his  original  illness. 

The  post-mortem  examination  for  which  Dr.  Geoffrey  Thomp- 
son had  arranged  was  made  on  February  i,  191 1,  by  Dr.  M. 
J.  Stewart,  and  his  report  is  as  follows:  "The  body  is  that  of  a 
somewhat  emaciated  man.  All  the  tissues  and  organs  exhibit 
an  extreme  degree  of  anaemia  and  the  blood  within  the  heart  and 
great  vessels  is  very  watery  in  appearance.  On  opening  the  ab- 
domen, the  peritoneum  is  found  to  be  free  from  disease,  although 
there  are  some  old  fibrous  adhesions  between  the  first  part  of  the 
jejunum  and  the  operation  cicatrix  in  the  anterior  abdominal 
wall,  as  also  between  the  liver  and  the  diaphragm.  The  cardiac 
end  of  the  oesophagus  is  anastomosed  to  a  loop  of  jejunum,  which, 
for  this  purpose,  has  been  brought  through  the  transverse  meso- 
colon. The  proximal  portion  of  jejunum  and  the  duodenum,  which 


COMPLETE    GASTRECTOMY.  349 

ends  in  a  cul-de-sac  underneath  the  liver,  appear  to  retain  pretty 
much  their  normal  dimensions,  but  at  the  seat  of  anastomosis 
and  for  a  short  distance  beyond  it,  the  jejunum  appears  to  be 
slightly  dilated.  The  whole  intestinal  tract,  however,  exhibits 
a  marked  degree  of  gaseous  distension,  and  in  the  large  intestine 
there  are  very  numerous  scybalous  masses  of  considerable  size. 
The  liver  is  pale  and  somewhat  fatty;  the  gall-bladder  normal. 
The  spleen  contains  a  large  and  very  old  infarct,  which  occupies 
nearly  the  middle  third  of  the  organ.  The  kidneys  are  extremely 
pale  and  anaemic,  while  the  capsules  strip  readily.  The  supra- 
rena's  are  normal.  There  is  no  evidence  of  malignant  disease  in 
any  part  of  the  abdomen.  A  few  of  the  retro-peritoneal  glands 
are  enlarged,  but  on  microscopical  examination  they  are  found 
to  be  quite  simple.  The  heart  muscle  is  very  pale  and  flabby. 
The  valves  are  normal.  The  aorta  and  coronary  arteries  are 
quite  healthy.  There  are  numerous  old  adhesions  on  both  sides 
of  the  chest.  The  lungs  are  extremely  oedematous ;  they  contain 
only  a  minimum  of  carbonaceous  pigment.  Microscopically  the 
kidneys  shew  well-marked  though  early  fibrosis,  involving  both 
the  interstitial  tissue  and  the  glomeruli.  The  chief  points  of  in- 
terest are:  (i)  Complete  absence  of  any  recurrence  or  dissemina- 
tion; (2)  the  very  profound  anaemia;  and  (3)  absence  of  any 
striking  jejunal  dilatation  at  or  near  the  site  of  anastomosis." 

The  photograph  of  the  specimen  brought  to  Leeds  was  taken 
in  my  laboratory.  It  shews  well  the  anastomosis  between  the 
oesophagus  and  the  jejunum,  the  slight  dilatation  of  the  jejunum, 
the  blind  rounded  end  of  the  duodenum,  and  the  absence  of  any 
secondary  growths. 


CHAPTER  XVII. 
GASTROSTOMY. 

The  operation  of  gastrostomy  consists  in  the  making  of  an 
opening  directly  into  the  stomach,  in  cases  of  obstruction  of  the 
oesophagus  or  cardiac  end  of  the  stomach,  for  the  purpose  of 
introducing  food  directly  into  the  interior  of  this  organ.  In  the 
earlier  cases  it  was  found  that  the  new  orifice  was  not  only  an 
inlet,  but  also  an  outlet;  that  it  permitted  the  free  escape  of 
food  and  gastric  juice,  and  that,  as  a  result  of  this,  the  skin 
around  the  opening  became  reddened  and  digested.  The 
condition  of  the  patients  was  often  one  of  the  most  intense 
misery.  The  skin  for  four  or  five  inches  around  the  new  orifice 
was  intensely  red,  raw,  and  excoriated ;  it  was  excessively  tender 
and  sensitive,  and  the  escape  on  to  it  of  the  acid  gastric  juice  gave 
rise  to  the  most  intolerable  smarting  and  burning  pain.  Meas- 
ures were,  therefore,  devised  for  the  purpose  of  making  a  val- 
vular opening — an  opening,  that  is,  that  would  permit  the  in- 
troduction of  fluids  into  the  stomach,  while  it  prevented  the 
escape  of  gastric  juice  or  digesting  food. 

A  large  number  of  operations  have  been  described,  and  prac- 
tised with  success,  and  the  surgeon  now  has  the  choice  of  several 
methods,  any  one  of  which  will  serve  his  purpose  fully. 

In  the  great  majority  of  instances  the  cause  which  determines 
the  necessity  for  the  operation  of  gastrostomy  is  malignant 
disease  of  the  oesophagus.  Simple  or  syphilitic  stricture  of  the 
pharynx  or  oesophagus  or  malignant  disease  of  the  cardiac  end  of 
the  stomach  may  also  call  for  the  performance  of  this  operation. 
In  cases  of  malignant  disease  of  the  oesophagus  it  is  important 
that  the  most  suitable  time  should  be  selected  for  the  performance 
of  the  operation.  It  was  formerly  almost  always  the  case  that 
the  surgeon  was  asked  to  operate  when  the  patient  was  in  the 

35° 


GASTROSTOMY.  35 1 

last  extremity  of  his  illness,  when  he  was  unable  to  take  any 
food,  or,  at  the  most,  only  a  few  ounces  daily,  and  when  his  con- 
dition was  so  bad  that  the  danger  of  the  operation — in  itself  a 
perfectly  simple  matter — had  become  considerable.  If  a  patient 
is  first  seen  when  in  this  deplorable  state,  it  is  most  desirable  that 
all  means  should  be  taken  to  improve  his  condition  before  the 
operation  is  undertaken.  It  will  sometimes  be  found  possible, 
though  often  perhaps  difficult,  to  pass  a  small  silk  catheter 
through  the  stricture  into  the  stomach.  If  this  can  be  done,  the 
catheter  should  be  left  in,  its  outer  end  being  secured  by  a  tape 
and  strapping  to  the  ear,  the  forehead,  or  the  neck.  Through 
the  catheter  several  pints  of  nourishing  fluids  can  be  poured  daily, 
to  the  evident  improvement  of  the  patient's  condition.  During 
a  week,  several  pounds  in  weight  may  be  gained  and  the  fitness  of 
the  patient  to  bear  the  operation  be  greatly  strengthened.  In 
one  patient  who  was  almost  starved  to  death  I  was  able  to  keep  a 
tube  in  for  six  weeks ;  during  this  time  she  gained  2 1  pounds  in 
weight.  Had  I  performed  gastrostomy  at  first,  the  result  would 
almost  certainly  have  been  fatal;  as  it  was,  the  operation  was 
borne  without  the  slightest  shock. 

In  all  bad  cases,  therefore,  feeding  through  an  oesophageal 
catheter  should  be  attempted  before  gastrostomy  is  performed. 

It  is  important  not  to  delay  too  long  in  the  advocacy  of 
operation.  It  is  equally  important  not  to  be  precipitate.  The 
operation,  though  of  the  greatest  benefit  to  many  patients,  is 
nothing  more  than  a  forlorn  and  final  measure  of  relief  to  prevent 
starvation;  to  many,  it  must  be  acknowledged,  it  has  something 
revolting  in  its  methods.  When  a  patient  can  take  enough  fluid 
food  by  the  mouth  to  keep  himself  alive  and  in  fair  condition  he 
is  not  a  suitable  subject  for  gastrostomy.  Early  operation  and 
late  operation  are  both  to  be  condemned.  The  proper  time  for 
operation  is  when  the  patient  is  ceasing  to  be  able  to  take  enough 
fluid  nourishment  to  keep  up  his  weight  and  strength,  and  it  is, 
therefore,  before  he  has  lost  of  both  so  much  that  his  power  of 
resistance  to  surgical  treatment  is  greatly  reduced. 


352  ABDOMINAL  OPERATIONS. 

The  operation  can  be  done  quite  easily  in  a  few  minutes 
under  cocaine  anaesthesia,  but  I  prefer  to  give  a  general  an- 
aesthetic if  it  can  safely  be  administered.  The  usual  prepara- 
tion of  the  skin  is  made.  Owing  to  the  great  wasting  of  the 
patient,  the  abdominal  wall  shelves  away  steeply  from  the 
costal  margin;  the  incision  is  made,  therefore,  through  an 
abdominal  wall  which  is  more  nearly  vertical  than  horizontal. 

A  great  variety  of  incisions  have  been  suggested.  Some 
are  vertical  and  pass  through  the  rectus,  or  the  rectus  is  bodily 
pulled  aside;  others  are  in  varying  degrees  of  obliquity.  The 
valvular  action  of  the  stomach  at  the  new  opening  is  effected 
in  several  ways.  In  my  opinion  the  operations  which  are  the 
most  satisfactory  are  the  following: 

1.  Senn's  operation  (E.  J.  Senn). 

2.  Kader's  operation. 

3.  Witzel's  operation. 

4.  Frank's  operation. 

I.  Senn's  Operation. — This  is  the  operation  which  I  have 
used  for  the  last  five  years.  It  is,  in  my  judgment,  the  best 
operation  for  these  reasons:  it  is  simple,  speedily  performed, 
effects  a  perfect  valvular  opening,  and  does  not  involve,  as  do 
some  of  the  methods,  a  sacrifice  of  some  part  of  a  stomach 
already  reduced  in  size  for  the  purpose  of  forming  a  cone 
which  is  pulled  through  an  incision  in  the  abdominal  wall  to  lie 
beneath  the  skin. 

The  operation  is  performed  in  the  following  manner: 
A  vertical  incision  is  made  over  the  left  rectus  muscle  near 
its  outer  border,  commencing  a  little  below  the  level  of  the  tip 
of  the  xiphoid  cartilage  and  continuing  downwards  for  about 
2 -2-  inches.  The  fibres  of  the  rectus  muscle  are  separated,  not 
divided,  and  the  peritoneal  cavity  is  opened.  If  the  separation 
is  done  with  the  finger  covered  by  gauze,  no  nerves  will  be  divided. 
The  stomach  is  then  sought  and  is  easily  recognised.  It  is  said 
that  the  transverse  colon  has  been  mistaken  for  the  stomach 
and  has  been  opened;    one  would  think  that  such  a  mishap  is 


GASTROSTOMY. 


353 


impossible,  for  there  is  not  the  smallest  resemblance  between 
the  two  viscera.  The  stomach  is  generally  found  at  once,  but, 
owing  to  the  fact  that  it  is  often  thin-walled  and  shrunken 
from  long  suppression  of  its  normal  activity,  it  may  lie  flaccid 
and  empty  at  the  back  of  the  stomach  chamber,  with  the  trans- 
verse colon  in  front  of  it.  When  the  colon  is  displaced  down- 
wards, it  comes  at  once  into  view.  It  is  picked  up,  drawn  for- 
wards to  the  parietal  incision,  and  a  portion  of  it,  as  far  removed 


Fig.  131. — Gastrostomy  (Senn's 
method).  The  stomach  is  opened 
and  the  tube  fixed  with  a  single 
stitch. 


Fig.  132. — Gastrostomy  (Senn's 
method).  The  first  purse-string 
suture. 


as  possible  from  the  pylorus,  is  selected  for  the  operation.  A 
point  about  midway  between  the  lesser  and  the  greater  curva- 
ture is  chosen  for  the  site  of  the  opening  into  the  stomach.  At 
this  point  a  small  incision  is  made  with  a  scalpel  of  sufficient 
size  to  admit  a  No.  10  or  12  Jaques  catheter  or  a  piece  of  drain- 
age-tube of  about  the  same  diameter.  The  catheter  or  tube  is 
passed  into  the  stomach  through  this  opening  for  a  distance  of 
two  to  three  inches,  and  is  then  fixed  by  a  single  catgut  stitch 
which  passes  through  all  the  coats  of  the  stomach,  at  the  edge 

VOL. I — 23 


354 


ABDOMINAL   OPERATIONS. 


of  the  incision,  and  then  picks  up  a  portion  of  the  tube.  When 
this  stitch  is  tightened,  the  tube  is  held  fast  and  remains  so  held 
until  the  catgut  is  absorbed — or  cuts  through — in  about  ten  days. 
The  tube  so  fixed  is  now  buried  in  an  inverted  cone  formed 
from  the  walls  of  the  stomach  b}^  the  insertion  of  three  purse- 
string  sutures.  The  first  purse-string  suture  is  applied  in  a 
circle  whose  centre  is  the  tube,  and  whose  radius  is  about  half 
an  inch.  The  suture  picks  up  the  stomach-wall  at  about  six 
points.     As  it  is  tightened,  the  tube  is  depressed  into  the  stomach 


Fig.  133. — Gastrostomy  (Senn's 
method).  The  first  purse-string 
suture  tied. 


Fig.  134. — Gastrostomy  (Senn's 
method).      The   second   purse-string 

suture. 


by  an  assistant  whose  other  hand  holds  the  stomach  steady, 
so  that  when  tied,  the  suture  closely  embraces  the  tube.  A 
second  suture  is  now  introduced  at  a  distance  of  half  an  inch 
from  the  tube,  picking  up  the  stomach-wall  at  seven  or  eight 
points.  As  it  is  tightened  and  tied,  the  tube  is  again  pushed 
inwards  so  that  the  suture  again  embraces  the  tube  closeh^  A 
third,  and,  if  necessary,  a  fourth,  suture  can  be  similarly  intro- 
duced. The  result  is  that  a  cone  of  the  stomach  is  inverted  into 
the  cavity  of  the  organ ;   and  in  the  centre  of  this  cone  there  lies 


GASTROSTOMY. 


355 


the  tube  or  catheter  closely  embraced  by  the  outer  wall  of  the 
stomach.  The  stitches  are  all 
tightened  with  sufficient  firm- 
ness to  embrace,  though  not  to 
constrict,  the  tube.  When  the 
last  stitch  has  been  cut  short, 
two  sutures  are  passed  above 
and  below  the  tube  in  order  to 
fix  the  stomach  to  the  parietal 
peritoneum.  These  sutures  in- 
clude the  posterior  sheath  of  the 
rectus  and  the  parietal  perito- 
neum on  each  side,  and  pick  up 
a  broad  strip  of  the  stomach 
about  I  inch  distant  from  the 
tube.  They  serve  to  draw  the 
stomach  up  to  the  parietal  in- 
cision and  to  fix  it  there  firmly. 
The  incision  is  now  closed  by 
suture  in  the  usual  manner;  a 
continuous  catgut  stitch  picks  up   the  parietal  peritoneum  and 


Fig.  135. — Gastrostomy  (Senn's 
method).  The  purse-string  sutures 
completed;  fixation  of  the  stomach 
to  the  anterior  abdominal  wall. 


Fig.  1 36. — Gastrostomy  (Senn's  method) .    Shewing  the  invaginated  cone  and 
the  line  of  the  purse-string  sutures. 

the  posterior  sheath  of  the  rectus,  and,  returning,  picks  up  the 


356  ABDOMINAL  OPERATIONS. 

anterior  sheath  of  rectus.  Two  stitches  are  used. — one  above 
and  one  below  the  tube.  The  skin  is  then  sutured  with  silk- 
worm gut. 

At  the  conclusion  of  the  operation  the  patient  is  fed :  about 
ten  ounces  of  warm  milk,  with  egg  or  brandy,  are  introduced 
through  the  tube  into  the  stomach.  At  the  outer  end  of  the 
tube  a  second  India-rubber  tube  is  attached,  a  piece  of  glass 
tubing  about  one  inch  in  length  forming  the  medium  of  at- 
tachment.    A  glass  funnel  fits  on  the  outer  end  of  this  second 

tube,   and    into    it    the    food   is 
^_^     ^_^  poured. 

This  method  ensures  an  abso- 
lutely secure  valvular  opening. 
I  have  never  known  leakage  to 
occur  from  the  opening.  At  the 
end  of  ten  or  twelve  days,  rarely 
earlier,  the  tube  will  be  found  to 
be  loose.  It  can  then  be  re- 
moved and  a  second  tube  be  in- 
troduced. It  is  better  to  keep  a 
!       tube  always  in  the   opening,  as, 

Fig.  i37.-Gastrostomy(Senn's      Otherwise,    there    may    soon    be 
method).    Diagram  of  the  position      evidence  of  Contraction,  and  the 

around    the    tube   of    the    purse-  .  ^         .  »  ^ 

string  sutures.  remtroduction    of    a    tube    may 

then  be  difficult. 

A  dressing  is  kept  on  the  wound  for  the  first  fortnight,  and 
is  secured  by  an  abdominal  bandage.  Through  the  dressing 
the  tube  passes,  and  its  outer  end  is  attached  to  the  bandage 
by  a  safety-pin. 

The  condition  of  the  patient  may  be  so  reduced  that  early 
and  frequent  feeding  is  necessary.  The  best  food  is  warmed 
milk  to  which  eggs  or  egg  and  brandy  are  added.  Water  should 
be  given  occasionally,  and  beef -tea  or  soups  may  afford  a  change. 
After  a  week  or  two  of  direct  feeding  the  patient  may  find  that 
he  is  again  able  to  swallow  thin  fluids  in  small  quantities.     This 


GASTROSTOMY. 


357 


he  should  be  encouraged  to  do,  if  no  distress  results,  for  the  loss 
of  the  opportunity  to  taste  food  is  often  the  most  serious  de- 
privation of  which  the  patient  complains.  In  some  cases  the 
patient  may  obtain  satisfaction  from  masticating  a  little  under- 
done beef,  mutton,  or  some  chicken  or  game,  and  feeding  him- 
self through  the  funnel  or  tube  with  the  finely  chewed  food. 
If  the  patient  will  not,  or  cannot,  use  his  mouth  and  teeth, 
great  care  must  be  exercised  to  keep  them  thoroughly  clean. 
The  teeth  should  be  brushed  three  or  four  times  daily,  and  the 
mouth  well  jElushed  with  some  fragrant  mouth-wash. 


Fig.  138. — Kader's  method  of 
gastrostomy:  tube  fixed  by  a  single 
stitch;  a  fold  on  each  side  is  raised 
up  by  a  Lembert  suture. 


Fig.  139. — Kader's  method  of 
gastrostomy:  first  layer  of  sutures 
tied,  second  layer  in  position. 


2.  Kader's  operation  consists  in  the  vertical  infolding  of  a 
portion  of  the  stomach  by  interrupted  sutures  passed  above 
and  below  a  tube  introduced  through  a  small  incision.  The 
tube  is  first  secured  by  a  single  catgut  stitch,  as  in  Senn's  opera- 
tion. Two  vertical  parallel  folds  of  the  stomach  are  then  raised 
up  on  each  side  of  the  tube  by  four  or  six  sutures.  When  these 
sutures,  which  include  only  the  serous  and  muscular  coats,  are 
tied  and  cut  short,  a  further  series  are  introduced  which  pick 


358 


ABDOMINAL   OPERATIONS. 


up  the  stomach- wall  on  each  side  of  the  original  line  of  stitches. 
On  tying  this  second  row  the  first  row  of  sutures  is  buried.  A 
reference  to  Figs.  98  to  100  will  make  matters  plain.  The  stom- 
ach is  then  fixed  to  the  anterior  abdominal  wall,  as  in  Senn's 
method.  It  will  be  seen  that  b}^  this  operation  exactl}''  the 
same  kind  of  valve  is  produced  as  by  Senn's  procedure.  The 
advantages  of  the  latter  over  Kader's  operation  are  that  the 
operation  is  more  speedy,  that  it  is  simpler,  that  fewer  stitches 


^ 


Fig.  140. — Kader's  method 
of  gastrostomy:  second  layer 
tied;  fixation  sutures  left  long. 


Fig.  1 4 1 . — -Kader's  method  of  gastrostomy 
the  parts  seen  in  section. 


are  required,  and  that  a  cone,  instead  of  a  cube,  is  made  to  pro- 
ject into  the  cavity  of  the  stomach. 

3.  Witzel's  Operation. — In  this  operation  the  stomach  is 
brought  into  the  wound,  and  opened  by  a  small  incision  into 
which  a  tube  is  fastened  by  a  single  catgut  stitch,  as  in  the  two 
operations  just  described.  The  tube  when  thus  secured  is  laid 
against  the  anterior  wall  of  the  stomach  and  is  buried  in  a  sort 
of  trough  or  gutter  formed  by  raising  up  a  fold  on  each  side  of 


GASTROSTOMY, 


359 


the  tube.  The  summits  of  the  folds  are  brought  together  o^^er 
the  tube  by  interrupted  sutures.  One  or  two  sutures  are  passed 
beyond  the  end  of  the  tube,  so  as  to  be  sure  that  the  opening 
into  the  stomach  is  also  walled  off.  About  two  inches  of  the 
tube  are  thus  covered  in  and  made  to  lie  in  a  sort  of  canal  in  the 
stomach-wall.  Witzel  himself  recommends  that  a  second  la^^er 
of  sutures  should  be  introduced,  but  this  is  quite  unnecessar}". 


Fig.    142. — Gastrostomy  (Witzel's  method). 


Marwedel  has  modified  Witzel's  method  by  passing  the  tube  be- 
tween the  mucous  and  muscular  coats  for  a  couple  of  inches 
between  the  openings  on  the  serous  and  mucous  surfaces.  There 
is  no  advantage  in  this. 

Witzel's  method  proves  most  satisfactory  in  practice.  In- 
deed, von  Mikulicz,  in  an  experience  of  150  cases,  is  so  satisfied 
with  the  results  of  both  Kader's  and  Witzel's  methods  that  he 
considers  that  there  is  no  excuse  for  the  introduction  of  more 


36o 


ABDOMINAL   OPERATIONS. 


complicated  methods.  I  have  used  both  and  have  found  both 
to  be  good,  but  for  the  reasons  I  have  already  given  I  consider 
that  Senn's  operation  is  better  than  either. 

4.  Frank's  Operation. — This  operation  has  received  a  great 
amount  of  support  from  many  operators.  Though  the  results 
are  good,  thev  are  no  better  than  those  seen  after  any  of  the 


Fig.    143. — Gastrostomy  (Frank's  method,  as  moditied  by  Kocher).     The  whole 
of  the  rectus  is  pulled  to  the  outer  side. 


preceding  operations  (indeed,  leakage  has  been  occasionally  ob- 
served), and  they  are  obtained  only  after  a  more  prolonged  and 
more  complex  operation. 

An  oblique  incision,  about  2^  inches  in  length,  is  made 
parallel  to  the  costal  margin  and  about  one  inch  from  it,  near 
the  outer  border  of  the  rectus.     The  abdomen  is  opened,  and 


GASTROSTOMY. 


361 


a  cone  of  the  stomach  close  to  the  cardiac  end  is  then  stitched, 
by  four  interrupted  sutures  or  by  a  continuous  suture,  to  the 
parietal  peritoneum  at  the  edge  of  the  incision.  A  second  in- 
cision is  now  made  over  the  costal  margin,  about  |  inch  in 
length,  at  a  distance  of  about  one  inch  from  the  first  incision. 
Between  the  two  incisions  the  skin  is  undermined  until  the  finger 


Fig.   144. — Gastrostomy  (Frank's  method).     The  operation  completed. 


can  be  passed  through  the  one  opening,  beneath  a  bridge  of 
skin,  and  out  of  the  other.  Beneath  this  bridge  of  skin  the 
cone  of  the  stomach  is  passed  until  its  apex  projects  like  a 
nipple  from  the  second  opening.  Here  it  is  stitched  or  is  held 
by  a  pair  of  hare-lip  pins,  which  transfix  it.  The  original 
woimd  is  now  completely  closed  by  suture.  The  tip  of  the 
stomach  cone  may  now  be  opened,  and  a  catheter  passed  into 


362  ABDOMINAL  OPERATIONS. 

the  stomach,  or  the  opening  may  be  deferred  for  twenty-four 
hours  or  more. 

As  von  jMikuhcz  and  others  have  shewn,  the  original  obhquity 
of  the  passage  does  not  long  persist;  the  tube,  after  a  time, 
passes  directly  backw'ards  into  the  stomach.  To  prevent  this, 
as  far  as  possible,  the  second  opening  must  be  made  well  over 
the  costal  margin,  whence  it  cannot  be  dragged  down  to  lie  in 
front  of  the  posterior  opening. 

This  operation  cannot  be  easily  performed  when  the  stomach 
is  very  much  shrunken  from  long-continued  emptiness.  It  is, 
moreover,  under  any  circumstances,  wasteful  in  the  amount  of  the 
stomach  which  is  used  up  by  the  formation  of  the  cone. 


CHAPTER  XVIII. 
JEJUNOSTOMY. 

Jejunostomy  is  an  operation  that  can  be  but  rarely  called 
for.  It  is  suitable  only  for  those  patients  suffering  from  ad- 
vanced malignant  disease  of  the  stomach  in  whom,  owing  to  the 
position,  extent,  or  character  of  the  growth,  gastro-enterostomy 
or  gastrostomy  is  deemed  imprudent  or  impossible. 

Indications  for  Operation. — (i)  Extensive  infiltration  of  the 
stomach  with  carcinoma,  when  there  is  little  or  no  healthy 
stomach-wall  that  can  be  utilised  for  the  purpose  of  gastrostomy. 

(2)  General  cicatricial  contraction  of  the  stomach,  simple 
in  character,  dependent  upon  the  swallowing  of  caustic  fluids. 

(3)  Neumann  has  suggested  that  in  cases  of  pronounced 
hyperchlorhydria  jejunostomy  should  be  performed  in  pref- 
erence to  gastro-enterostomy.  He  points  out  that  the  intensely 
acid  secretion  of  the  stomach,  passing  into  the  jejunum  through 
the  new  opening,  may  produce  ulceration,  which  will  rapidly 
destroy  the  intestinal  wall  and  lead  to  perforation — that  is  to 
say,  a  peptic  ulcer  of  the  jejunum  results,  in  a  manner  precisely 
similar  to  that  occurring  when  a  peptic  ulcer  of  the  first  portion 
of  the  duodenum  develops.  Peptic  ulcer  of  the  jejunum  is 
recorded  by  Braun,  Halm,  Kausch,  Korte,  Steinthal,  Hadra 
and  Neumann,  and  others.  In  many  cases  the  ulcer  has  caused 
death  by  perforation,  and  in  all  there  was  a  great  excess  of  free 
hydrochloric  acid. 

(4)  Cackovie  and  others  have  suggested  that  in  cases  of 
persistent  hsematemesis  rest  might  be  afforded  to  the  stomach 
by  an  artificial  mouth  in  the  jejunum.  This  plan  received  the 
sanction  and  approval  of  Professor  Mikulicz.  It  is  also  suitable 
in  certain  cases  of  chronic  gastric  ulcer  where,  owing  to  massive 
inflammatory  adhesions  between  the  stomach  and  the  pancreas, 

363 


364 


ABDOMINAL   OPERATIONS. 


the  ideal  procedure — excision — cannot  be  performed.  In  these 
cases  gastro-enterostomy,  either  the  anterior  operation  with  a 
lateral  antero-anastomosis  or  the  modified  Roux  operation  in 
Y,  is  the  routine.     In  many  cases  these  large  chronic  ulcers,  sur- 


Fig.    145. — Jejunostomy  (Maydl's  method). 


rounded  by  a  mass  of  inflammatory  tissue,  do  not  heal  after  an 
anastomosis.  In  such  cases  jejunostomy  combined  with  the 
modified  Roux  operation  affords  complete  physiological  rest  for 
the  stomach,  and  promotes  the  healing  of  the  ulcer. 


JEJUNOSTOMY. 


36  = 


Several  methods  for  the  easy  performance  of  the  operation 
have  been  suggested.  Only  three  are  of  value.  The  first  was 
suggested  by  Maydl;  the  second  is  the  modification  of  Witzel's 
operation,  which  I  was  the  first  to  suggest ;  the  third  is  Ma3^o  Rob- 
son's  method. 

Maydl's  Operation. — In  this  operation  the  abdomen  is  opened 
by  a  small  incision  through  the  left  rectus  muscle,  and  the  upper 
end  of  the  jejunum  is  sought.     The  bowel  is  cut  completely 


Fig.    146. — -Jejunostomy  (adaptation  of  Witzel's  method  as  used  by  the  author). 

across,  and  the  proximal  cut  end  is  implanted  into  the  side  of  the 
distal,  a  few  inches  from  its  divided  end.  The  distal  open  end 
is  then  stitched  to  the  abdominal  wall.  The  figure  (Fig.  145) 
will  explain  the  exact  condition  of  things.  The  similarity  of  this 
method  to  that  adopted  in  Roux's  operation  of  gastro-enteros- 
tomy  in  Y  is  at  once  apparent. 

Second  Method. — The  following  is  the  description  of  the 
method  I  carried  out  in  my  first  case  ("Brit.  Med.  Jour.,"  June, 
1902) : 


366  ABDOMINAL   OPER.\TIONS. 

The  abdomen  was  opened  a  little  to  the  left  of  and  above 
the  umbilicus,  through  the  rectus  muscle,  whose  fibres  were 
split.  The  duodenojejunal  junction  was  sought,  the  jejunum 
traced  downwards  for  six  or  eight  inches,  and  a  loop  drawn 
out  of  the  abdomen.  On  the  side  of  this  loop  farthest  from  the 
mesentery  a  small  longitudinal  incision  was  made,  opening  the 
bowel,  and  a  piece  of  drainage-tube  about  the  size  of  a  No. 
12  catheter  was  introduced,  and  fixed  by  a  single  catgut  stitch, 
which  included  the  cut  edge  of  the  bowel  and  the  side  of  the 
tube.  The  tube  was  then  laid  along  the  bowel  upwards  to- 
wards the  duodenojejunal  flexure.  A  continuous  stitch  was 
now  passed  from  side  to  side  of  the  groove  made  by  the  tube, 
so  that  the  tube,  when  the  stitch  was  tightened,  was  buried  by 
the  overlapping  of  the  edges  of  the  groove.  The  stitch  was 
begun  about  f  inch  below  the  opening  in  the  jejunum,  so  that 
any  leakage  there  might  be  effectually  prevented.  About  two 
inches  of  the  tube  were  covered  by  the  stitch,  which  was  then 
tied  and  cut  short.  The  line  of  suture  in  the  bowel  was  then 
made  fast  to  the  anterior  abdominal  wall  by  a  stitch  at  each 
extremity,  and  the  abdominal  incision  was  tightly  closed  around 
the  tube,  which  projected  for  about  ten  inches. 

When  the  patient  is  fed  through  such  a  tube,  a  funnel  is 
fixed  on  to  the  end,  and  food  poured  in  slowly.  At  the  first  only 
six  ounces  are  introduced,  but  after  the  first  few  days  up  to  a 
pint  may  be  given  in  the  space  of  ten  minutes. 

The  opening  in  the  jejunum  is  made,  therefore,  at  approxi- 
mately the  point  where  Schlatter  made  the  oesophago-intestinal 
anastomosis  in  his  case  of  complete  gastrectomy.  It  is  clear 
from  this  case  that  enough  food  can  be  taken  by  the  jejunum 
to  enable  weight  to  be  gained  and  the  general  well-being  of  the 
patient  to  improve.  If  a  jejunostomy  were  performed  for  any 
non-malignant  condition  of  the  stomach,  the  probability  would 
be  that,  as  in  Schlatter's  case,  a  decided  increase  in  the  capacity 
of  the  jejunum  would  he  demonstrable,  aftording  a  reservoir  for 
the  food. 


JEJUXOSTOMY. 


367 


Mayo  Robson's  Method. — Mayo  Robson  has  described  (Trans. 
Rov.  Med.  Chir.  Soc,  1905)  a  method  of  jejunostomy  which  de- 
pends upon  the  exclusion  of  a  loop  of  intestine  which  is  brought 
to  the  surface  for  the  introduction  of  a  tube.     He  writes: 

"  The  operation  I  have  performed,  which  I  believe  is  new,  con- 
sists in  taking  a  loop  of  the  beginning  of  the  jejunum  just  suf- 


Fig.  147. — Jejunostomy  (Mayo  Robson's  method). 

ficiently  long  to  reach  the  surface  without  tension.  The  two 
arms  of  the  loop  are  short-circuited  about  three  or  four  inches 
from  the  surface,  the  short-circuiting  being  done  either  by  means 
of  sutures  around  a  decalcified  bone  bobbin  or  by  sutures  alone. 
Personally  I  prefer  the  fonner. 

"A  small  incision  is  then  made  into  the  top  of  the  loop  just 


368  ABDOMINAL  OPERATIONS. 

large  enough  to  admit  a  No.  12  Jaques  catheter,  which  is  inserted 
and  passed  for  three  inches  down  the  distal  arm  of  the  loop.  This 
is  fixed  to  the  margin  of  the  incision  in  the  gut  by  a  silk  or  a  Pagen- 
stecher  suture,  and  the  entrance  of  the  tube  into  the  bowel  is 
further  guarded  by  two  purse-string  sutures,  one  over  the  other. 
The  top  of  the  loop  is  fixed  to  the  skin  by  one  or  two  stitches  and 
the  wound  closed.  The  patient  can  then  be  fed  at  once  with  some 
peptonised  milk  and  brandy.  The  whole  operation  can  be  done 
in  from  fifteen  to  twenty  minutes  and  with  very  little  viscera 
exposure.    , 

"  Should  the  patient  be  too  ill  to  bear  the  little  extra  time  oc- 
cupied by  the  short-circuiting,  the  tube  may  be  inserted  as  directed 
and  surrounded  by  two  or  three  purse-string  sutures,  a  proceeding 
which  can  be  accomplished  in  a  few  minutes.  In  this  case  the 
loop  of  bowel  must  not  be  brought  to  the  skin,  but  had  better  be 
fixed  by  sutures  to  the  peritoneal  margin  and  the  aponeurosis,  in 
order  to  leave  part  of  the  lumen  of  the  attached  loop  within  the 
abdomen  for  the  direct  passage  outwards  of  the  intestinal  fluid 
with  the  bile  and  pancreatic  secretion." 

The  same  variety  of  food  may  be  given  in  jejunostomy  as  in 
gastrostomy;  the  staple  article  of  diet  should  be  peptonized 
milk.  In  some  cases  a  duodenostomy  may  be  preferred  to  gas- 
trostomy. Hartmann  has  recently  reported  an  example  of 
duodenostomy  for  a  cicatricial  narrowing  of  the  stomach  follow- 
ing upon  the  swallowing  of  a  caustic  fluid.  A  duodenal  mouth 
may  be  considered  as  more  efficient  than  one  opening  into  the 
jejunum,  in  that  the  food  is  introduced  into  the  bowel  at  a 
point  higher  than  the  orifice  of  the  ampulla  of  Vater.  For  the 
performance  of  this  operation  the  second  method  above  described 
is  the  most  satisfactory. 


CHAPTER  XIX. 
GUNSHOT  WOUNDS  OF  THE  STOMACH. 

Gunshot  wounds  of  the  stomach  vary  greatly  in  character 
and  in  treatment,  according  to  the  nature  of  the  weapon  which 
produces  them.  In  the  South  African  War  the  rifles  used  by 
both  the  combatants  delivered  a  bullet  of  small  size,  travelling 
with  an  extremely  high  velocity.  The  result  was  that  there 
was  a  cleavage  rather  than  an  actual  destruction  of  the  tissues, 
and  in  those  cases  where  a  bullet  traversed  the  abdominal 
cavity  it  was  found  that  when  the  stomach  or  intestines  were 
wounded,  there  was  no  leakage  of  the  visceral  contents,  and  that 
healing  generally  occurred  without  complication,  especially  in 
the  case  of  a  fasting  man.  It  would  appear  that  peristalsis  comes 
to  an  end  the  instant  the  patient  is  struck,  and  the  omentum, 
or  a  neighbouring  coil  of  intestine,  closes  the  minute  line  of  cleav- 
age, thus  preventing  fsecal  extravasation. 

The  lessons  of  this  war,  however,  have  no  application  in 
civil  practice.  The  rude  weapons  of  the  suicide  or  the  would-be 
murderer  are  often  clumsy  and  uncertain.  With  them  a  larger 
bullet  is  used  and  the  rate  of  velocity  is  very  much  less.  There 
are,  as  a  result,  a  large  destruction  of  tissue  and  a  crushing  or 
bruising  over  a  wide  area.  In  addition  to  the  perforation  in  a 
gunshot  wound  made  by  such  a  weapon  there  is  a  considerable 
amount  of  contusion  and  of  rough  damage  to  the  immediately 
adjacent  parts. 

Sir  Frederick  Treves  gave  it  as  his  opinion  that  it  is  in- 
advisable to  operate  in  cases  in  which  the  abdomen  is  traversed 
above  the  umbilicus  owing  to  the  multiple  character  of  the  in- 
juries;  while  the  cases  in  which  the  abdomen  is  traversed  below 
the  umbilicus  get  well  without  operation. 

Forgue  and  Jeanbrau  ( "  Rev.  de  Chir.,"  September  and  Octo- 

VOL.  I — -24  369 


370 


ABDOMINAL   OPERATIONS. 


Fig.    148. — Relations  of  anterior  wall  of  stomach 
(Testut) . 


ber,  1903)  have  collected  the  notes  of  112  cases  of  gunshot  wound 

of  the  stomach  in 
which  the  lesion  was 
verified  either  at  the 
postmortem  examina- 
tion or  at  an  opera- 
tion. In  64  of  these 
cases  the  ball  passed 
completely  through 
the  stomach,  wound- 
ing both  surfaces.  In 
some  cases  only  one 
wall  was  injured,  the 
ball  remaining  in  the 
stomach,  or  passing, 
in  one  case,  into  the 

intestine.     In  other  cases  the  bullet  had  struck  a  curvature  and 

clipped  a  piece  away. 
Seven  of  the  cases 

died   of    haemorrhage, 

which  was  due  gener- 
ally to  the  wounding 

of     a     large     arterial 

trunk,    such     as     the 

coronary.       In    one 

case,   related  by  Gui- 

nard     as     having    oc- 
curred   at    the    Lari- 

boisiere    Hospital,    an 

abdominal  exploration 

was    undertaken    in    a       Fig.  149- — Relations  of  posterior  wall  of  stomach 
1  .  (Testut). 

patient  who  presented 

no  signs  of  injury  except  an  abundant  haematemesis.  A  very 
minute  examination  of  the  stomach  was  made,  but  nothing 
abnormal  was  found.     The   patient  died,  and  at  the  autopsy 


GUNSHOT   WOUNDS   OF    THE    STOMACH.  37 1 

the  bullet  was  found  free  in  the  peritoneal  cavity.  It  had  not 
perforated  any  viscus,  but  on  examining  the  interior  of  the 
stomach  a  wound  of  the  mucosa  close  to  the  pylorus  was  found,  of 
the  size  of  a  franc-piece.    This  was  the  source  of  the  haemorrhage. 

Peritoneal  infection  depends  upon  the  size  of  the  wound  and 
upon  the  state  of  repletion  of  the  organ.  If  the  stomach  is  full, 
and  if  vomiting  occurs,  the  contents  escape  freely  into  the  gen- 
eral cavity  of  the  peritoneum. 

Spontaneous  recovery  is  possible.  Socin  records  the  case  of 
a  man  who  was  shot  in  the  abdomen.     It  was  thought  that  the 


Fig.  150. — ^The  two  preceding  figures  superimposed.  The  unshaded  area 
shews  the  only  part  of  the  stomach  which  can  be  woimded  without  injur}-  being 
done  to  other  organs  (Forgue  and  Jeanbrau). 

Stomach  was  woimded,  but  the  patient  recovered  without  opera- 
tion. Five  months  later  he  died  of  a  "medical  illness."  At  the 
autopsy  two  wounds  of  the  stomach  soimdly  cicatrised  were 
seen.  Spontaneous  heahng  such  as  this  depends  upon  the 
emptiness  of  the  stomach,  the  smaU  size  of  thewoimd,  and  the 
plugging  of  the  wound  by  omentum,  or  upon  the  formation  of  a 
gastric  fistula,  which  permits  the  instant  escape  of  contents  to 
the  exterior,  as  in  the  oft-quoted  case  of  Alexis  St.  Martin  and 
in  others  related  by  Baudens,  Cannizaro,  and  T.  Smith. 

In  all  cases  of  revolver  or  pistol  wound — indeed,  it  may  be 
said,  in  all  forms  of  gunshot  wound — of  the  stomach  in  cbnl 


372  ABDOMINAL  OPERATIONS. 

practice,  the  abdomen  should  be  opened  with  the  utmost  ex- 
pedition. The  records  of  the  cases  collected  by  Forgue  and 
Jeanbrau  shew  that  the  mortality  increases  in  direct  proportion 
to  the  delay.  The  result  of  their  enquiries  is  shewn  by  the 
following  table: 

WOUND  OF  THE  STOMACH  ALONE,  WITHOUT  OTHER  VISCERA. 

Recovery.  Death. 

(o)    Intervention  within  six  hours 9  4  cases. 

(b)  Intervention  without  mention  of  time 2  4     " 

WOUND  OF  THE   STOMACH,  WITH   OTHER  VISCERA. 

Recovery.  Death. 

(a)    Intervention  within  six  hours   13  16  cases. 

;  (b)    Intervention  within  six  to  twelve  hours 2  11       " 

(c)  Intervention  after  twelve  hours 2  ii       " 

{d)    Intervention  without  mention  of  time 3  5       " 

In  examining  the  stomach  the  utmost  care  should  be  exercised. 
The  figures  given  by  Forgue  and  Jeanbrau  shew  that  it  is  not 
unlikely  that  some  other  damage  will  be  inflicted  by  a  bullet 
which  traverses  the  stomach.  Search  for  such  an  injury  must 
be  made,  and  any  wounds  so  found  must  be  appropriately  dealt 
with.  So  far  as  the  wound  in  the  stomach  is  concerned,  the 
edges  must  be  trimmed  or  turned  in  by  suture. 

DETAILS  OF  THE  OPERATION. 

The  usual  preliminaries  having  been  observed,  the  abdomen 
is  opened  by  a  free  incision  in  the  middle  line  above  the  um- 
bilicus. In  certain  cases — in  those,  for  example,  in  which  the 
stomach  is  wounded  near  the  cardiac  orifice — a  very  free  ex- 
posure may  be  necessary,  and  the  median  incision  alone  may  be 
inadequate.  Auvray  has  advised  that  in  such  circumstances 
a  second  incision  should  be  made  from  the  upper  end  of  the 
central  one,  downwards  and  to  the  left  along  the  costal  margin, 
which  may,  if  necessary,  be  partly  excised.  In  all  my  opera- 
tions upon  the  stomach,  including  a  complete  gastrectomy,  I  have 
never  found  the  need  of  anything  more  than  a  central  incision. 

The  abdomen  being  opened,  a  general  inspection  of  the  parts 
is  made.  There  may  be  much  blood-stained  fluid  and  perhaps 
the  contents   of  the   stomach  or  intestine  in   the  peritoneum. 


GUNSHOT   AVOUNDS   OF    THE    STOMACH.  373 

A  rapid  but  efficient  cleansing  is  then  necessary.  The  stomach 
is  then  picked  up  with  a  piece  of  gauze,  to  ensure  a  firmer  hold- 
ing, and  the  whole  of  the  anterior  surface  carefully  and  method- 
ically inspected.  A  little  bubbling  of  froth  or  the  sizzling 
noise  made  by  the  escape  of  gas  may  be  enough  to  direct  at- 
tention to  the  wounded  spot ;  or  if  a  vessel  of  moderate  size 
has  been  wounded,  the  continued  escape  of  blood  will  direct 
attention  to  the  point  of  injury. 

If  a  wound  on  the  anterior  surface  of  the  stomach  be  dis- 
covered, it  should  be  closed  at  once  by  suture.  As  a  rule,  no 
excision  of  the  edge  of  the  rent  is  necessary,  but  if  there  be  much 
contusion  or  fraying,  then  a  free  trimming  away  of  the  damaged 
wall  may  be  necessary.  If  the  opening  be  of  sufficient  size,  it 
may  be  made  use  of  for  purposes  of  digital  exploration  or  in- 
spection before  being  sutured. 

The  wound  is  closed  by  a  double  layer  of  stitches,  the  inner 
including  all  the  coats  of  the  viscus,  the  outer  only  the  serous 
and  muscular  coats. 

The  anterior  surface  having  been  made  perfect,  an  examina- 
tion of  the  posterior  is  necessary.  This  may  be  effected  either 
by  an  opening  through  the  gastrocolic  omentum  at  the  lower 
border  of  the  stomach,  as  advised  by  Forgue  and  Jeanbrau,  or 
by  turning  up  the  transverse  colon  and  opening  the  transverse 
mesocolon. 

There  may  or  may  not  be  a  second  opening  of  exit  on  the 
posterior  surface,  and  such  an  opening  may  or  may  not  be  near, 
or  opposed,  to  the  anterior.  The  bullet  which  has  injured  the 
anterior  wall  may  remain  in  the  stomach,  be  vomited,  be  passed 
on  into  the  duodenum,  or  may  penetrate  the  posterior  wall. 
The  surgeon,  however,  cannot  neglect  to  make  the  most  scrupu- 
lous examination  of  the  posterior  wall,  and  if  a  rent  be  found 
therein,  he  must  deal  with  it  as  with  the  anterior  wound. 

A  search  for  other  injuries  must  be  made.  It  is  remarkable 
how'  often  they  are  overlooked.  Forgue  and  Jeanbrau  quote 
many  cases  where,  at  the  postmortem  examination,  gross  dam- 
ages,  overlooked   at   the   operation,   were   laid  bare.     Bertram 


374  ABDOMINAL   OPERATIONS. 

records  a  case  where  the  spleen  and  the  left  kidney  were  found 
injured;  Briddon,  one  where  four  perforations  of  the  small  in- 
testine were  found;  Gabzewicz,  one  where  an  injury  to  the 
colon  was  seen ;  and  Poncet  and  others,  examples  of  injury  to  the 
liver.  The  minutest  search  must  be  made  despite  the  fact  that, 
because  of  the  patient's  collapse  from  shock  or  hsemorrhage,  a 
prolongation  of  the  operation  is  not  without  its  own  danger. 

In  not  a  few  recorded  cases  the  movements  of  the  surgeon 
are  greatty  hindered  by  the  copious  amount  of  blood-stained 
fluid  in  the  general  peritoneum.  No  sooner  is  the  field  of 
operation  cleared  than  a  slow  oozing  of  blood  or  deeply  blood- 
stained fluid  causes  further  dela}^  by  obscuring  all  things. 
Professor  Forgue,  in  1897,  drew  attention  to  a  most  important 
point,  by  suggesting  that  the  patient  should,  in  such  circum- 
stances, be  placed  in  the  semi -recumbent  position  at  an  angle 
of  45  degrees.  The  viscera  fall  away  from  the  wound,  and 
venous  oozing  is  checked. 

In  some  few  instances  the  loss  of  substance  caused  by  the 
blow  of  the  bullet  has  been  so  great  that  when  the  wound  is 
securely  closed,  a  marked  narrowing — in  one  case  an  oblitera- 
tion at  the  pylorus — has  been  produced.  It  would  be  necessary, 
then,  to  perform  gastro-enterostomy  to  afford  an  efficient  outlet, 
or  to  use  the  rent  at  the  pylorus  for  the  purposes  of  a  gastro- 
duodenostomy. 

Closure  of  the  perforation  having  been  effected,  the  abdomen 
is  cleansed  by  wiping  or  by  lavage,  and  the  abdominal  wound 
is  closed.  Drainage  may  or  may  not  be  necessary.  Forgue 
advises  its  unvaried  adoption,  for  the  reason  that  a  bullet  trav- 
ersing the  clothes  and  the  abdominal  wall  is  certain  to  carry 
infection  with  it.  Karlinski  performed  experiments  upon  rab- 
bits which  were  wrapped  in  garments  made  of  military  cloth. 
They  were  shot  in  the  abdomen,  and  the  abdomen  opened  and 
its  contents  subjected  to  the  most  minute  examination.  Fine 
fragments  of  cloth  were  found  in  the  peritoneum.  Drainage 
may  be  effected  through  the  anterior  incision  or  through  poste- 
rior incisions  specially  made  for  the  purpose. 


SECTION  III. 
OPERATIONS  UPON  THE  INTESTINES. 


CHAPTER  XX. 
INTESTINAL  LOCALISATION. 

It  would  undoubtedly  be  a  matter  of  great  interest  and 
importance  to  the  surgeon  to  discover  if  there  were  any  means 
of  determining  with  accuracy  the  exact  position  in  the  intestine 
held  by  any  selected  loop.  Much  labour  and  patience  have 
been  expended  upon  this  task,  and  though  the  results  are  not 
so  satisfactory  as  could  be  wished,  they  have,  nevertheless,  af- 
forded us  some  valuable  information.  It  is  to  Mall  ("Bulletin of 
the  Johns  Hopkins  Hospital,"  1898,  vol.  ix,  p.  197)  and  to  Monks 
(Trans.  Amer.  Surg.  Assoc,  1903,  p.  405)  that  we  are  in- 
debted for  the  best  work  in  this  matter.  There  are  certain  in- 
herent difficulties  in  the  subject.  The  intestine,  for  example, 
may  be  of  any  length  from  fifteen  to  thirty  feet ;  the  position  of 
all  its  parts  is  hable  to  some  variation  from  time  to  time,  owing 
to  unequal  filling,  to  the  position  of  the  individual,  and  so  forth; 
and  the  changes  which  occur  in  the  bowel  itself  and  in  the  mes- 
entery by  which  it  is  attached  are  not  sharp  and  abrupt,  but 
gradual  throughout. 

Mall,  in  his  examination  of  the  condition  of  the  mesenteric 
loops  in  41  bodies,  found  what  he  called  a  normal  arrangement 
in  21  of  them.  The  sweep  of  the  mesentery,  and  therefore  of 
the  bowel  which  it  attached,  in  this  "normal"  arrangement 
was  as  follows:  first  to  the  left,  then  upwards  and  to  the  right, 
then  obliquely  downwards  and  to  the  left  iliac  region,  then  into 
the  pelvis,  and  finally  up  to  the  right  in  the  ileocecal  region. 

375 


3/6  ABDOMINAL   OPERATIONS. 

It  is  more  than  probable,  howeA'er,  that  during  health  there  is 
a  constant  journeying  of  the  large  and  small  intestine  from  one 
part  of  the  abdomen  to  another,  and  that  two  loops  of  intestine 
which  at  one  moment  are  in  contact  may,  in  a  few  seconds,  be 
widely  separated.  This  is  shewn  during  operations  for  gun- 
shot wounds.  Thus  in  a  case  of  bullet  wound  where  the  shot 
traversed  the  abdomen  directh^  from  front  to  back,  a  little 
in  front  of  the  left  anterior  superior  spine  of  the  ilium,  the 
jejunum  in  four  places,  the  transverse  colon  in  two  places,  and 
the  lower  end  of  the  sigmoid  were  wounded. 

Monks  found  that  in  normal  conditions  the  upper  six  feet 
or  so  of  the  intestine  were  generally  confined  to  the  left  hypo- 
chondriac region,  occupA^ing  a  deep  fossa  there,  under  the  ribs, 
in  such  a  position  that  its  coils  would  not  usually  be  encountered 
through  any  of  the  ordinary  abdominal  incisions.  The  middle 
portion  usually  occupied  the  middle  part  of  the  abdomen,  while 
the  lower  part  of  the  intestine  lay  generally  in  the  pelvis  and  in 
the  right  iliac  fossa.     He  writes: 

"  In  order  roughly  to  indicate  on  the  outside  of  the  body  the 
positions  ordinarity  occupied  by  the  upper,  middle,  and  lower 
thirds  of  the  intestine,  I  have  found  that  two  straight  lines  run- 
ning obliquely  across  the  abdomen  at  the  two  ends  of  and  at 
right  angles  with  the  line  of  the  mesenteric  root  will  divide  the 
abdomen  into  three  regions,  each  of  which  will  contain  in  raost 
bodies  about  one-third  of  the  intestinal  tube,  the  upper  third 
being  in  the  first  region,  the  middle  third  in  the  second  region, 
and  the  lower  (or  third)  third  in  the  third  region,  as  shewn  in 
the  diagrams. 

"It  will  thus  be  seen  that  an  incision  anywhere  above  the 
first  line  will  probably  disclose  loops  belonging  to  (or  near)  the 
upper  third  of  the  intestine,  anywhere  between  the  first  and 
second  lines,  loops  belonging  to  the  middle  third,  and  anywhere 
below  the  second  line,  loops  belonging  to  the  lower  third.  This 
appears  to  be  a  pretty  good  general  inile  in  intestinal  topography, 
to  assist  us  in  determining,  while  making  our  incision,  what  part 
of  the  bowel  we  are  likely  to  meet  with  first.  We  should  not  for- 
get, however,  that  there  are  occasional  and  marked  exceptions  to 
this  rule." 


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377 


378  ABDOMINAL   OPERATIONS. 

When  the  small  intestine  is  examined  from  end  to  end,  it  is 
found  that  it  is  funnel-shaped,  and  that  the  upper  part  of  the 
jejunum  is  of  greater  diameter  than  the  lower  part  of  the  ileum. 
This  is,  of  course,  well  recognised  clinically  by  the  fact  that  the 
further  a  gall-stone  travels  down  in  the  bowel  the  more  likely 
it  is  to  become  impacted ;  that  a  stone  which  easily  passes  through 
the  jejunum  is  arrested  in  the  ileum.  The  diameter  of  the  last 
three  or  four  feet  of  the  ileum  shews  little  or  no  narrowing  as  a 
rule. 

As  the  bowel  narrows  in  this  way  its  walls  also  become 
thinner.  The  upper  part  of  the  jejunum  feels  thick  when  rolled 
between  the  fingers,  owing  to  the  presence  of  large  and  numerous 
valvulae  conniventse.  The  ileum  is  thin,  and  its  walls  are  more 
supple.  The  last  two  feet,  approximately,  of  the  ileum  again 
become  thicker,  and  just  above  the  ileocascal  valve  the  muscular 
tissue  in  the  ileum  shews  a  decided  increase.  The  condition 
of  the  mesentery  is  exactly  the  opposite  of  this:  the  thin- 
nest part  is  that  which  runs  to  the  upper  end  of  the  jejunum; 
the  thickest  part  is  that  which  runs  to  the  lower  end  of  the 
ileum.  The  mesentery,  therefore,  becomes  gradually  thicker  the 
lower  down  it  lies.  This  increased  thickness  is  largely  due  to 
the  deposit  of  fat,  at  first  in  thin  scattered  islets,  later  in  larger 
thick  slabs  between  the  leaves  of  the  mesentery.  The  upper  part 
of  the  mesentery  is  thin  and  translucent.  Monks  draws  attention 
to  a  point  of  importance.     He  writes : 

' '  If  one  raises  a  loop  from  the  uppermost  part  of  the  intes- 
tine and  holds  it  in  such  a  position  that  the  light  will  shine 
through  the  mesentery,  one  will  notice,  in  that  part  of  the  mes- 
entery close  to  the  gut,  little  transparent  spaces  between  the 
vasa  recta.  Some  of  these  'lunettes,'  as  I  call  them,  are  almost 
always  present  opposite  the  upper  part  of  the  gut  even  in  the 
thickest  mesenteries.  I  have  found,  as  a  rule,  that  they  gradu- 
ally grow  smaller,  become  streaked  with  fat,  and  disappear 
at  about  the  eighth  foot.  They  may,  however,  in  exceptional 
cases,  persist  to  the  end  of  the  gut." 


INTESTINAL   LOCALISATION.  379 

Some  idea  of  the  position  occupied  by  any  loop  drawn  out  by 
chance  through  an  abdominal  incision  may  be  determined  by 
pulling  upon  it  until  its  mesentery  is  taut.  The  finger  is  then 
passed  along  the  upper,  right,  side  of  the  mesentery  until  the 
posterior  abdominal  wall  is  reached.  The  relation  of  the  point 
reached  to  the  line  of  the  attachment  of  the  mesentery  will  then 
be  recognised.  In  this  way,  moreover,  by  passing  the  finge:p'on 
both  sides  of  the  mesentery,  its  upper  right  side  will  be  distin- 
guished from  its  lower  left  side,  and,  therefore,  the  direction  in 
which  the  bowel  is  running  is  determined. 

The  arrangement  of  the  vessels  in  the  mesentery  has  been 
studied  by  Dwight  and  Monks.     Dr.  Monks  writes: 

"  Opposite  the  upper  part  of  the  bowel  the  mesenteric  vessels 
are  distinctly  larger  than  opposite  any  other  part  of  it.  These 
vessels  grow  smaller  and  smaller  as  we  pass  downward  until  the 
lower  third  of  the  gut  is  reached,  where  they  remain  about 
the  same  size  as  far  as  the  ileocaecal  valve.  The  arrangement 
of  the  mesenteric  vessels  has  some  features  which  intimately 
concern  the  subject  in  hand,  and  which  I  shall  describe  with 
some  detail.  Diagrammatically  speaking,  the  main  branches 
of  the  superior  mesenteric  artery  unite  with  each  other  by 
means  of  loops,  which  are  called,  for  convenience,  'primary 
loops' ;  in  some  parts  of  the  tube,  'secondary  loops' ;  and  even 
occasionally  'tertiary  loops'  are  superimposed  upon  these. 
From  these  loops  little  straight  vessels — ^the  vasa  recta  already 
referred  to — run  to  the  bowel,  upon  which  they  ramify,  alterna- 
ting, as  a  rule,  as  to  the  side  of  the  intestine  which  they  supply. 
The  mesenteric  veins  are  arranged  in  a  manner  somewhat  similar 
to  the  arteries.  Opposite  the  upper  part  of  the  bow^el  there  are 
only  primary  loops.  Occasionally  a  secondary  loop  appears, 
but  it  is  small  and  insignificant  as  compared  with  the  primary 
loops,  which  are  large  and  quite  regular.  As  we  proceed  down 
the  bowel  secondary  loops  become  more  numerous,  larger,  and 
approach  nearer  to  the  bowel  than  the  primary  loops  in  the  upper 
part.  As  a  rule,  secondary  loops  become  a  prominent  feature  at 
about  the  fourth  foot.  As  we  continue  farther  downward  the 
secondary  loops  (and,  possibly,  tertiary  loops)  become  still 
more  numerous  and  the  primary  loops  smaller,  the  loops  all  the 


Fig.  153. — A  loop  of  intestine,  the  middle  of  which  is  exactly  three  feet 
from  the  end  of  the  duodenum.  The  gut  is  of  large  size.  The  mesenteric  loops 
are  primary,  and  the  vasa  recta  large,  long,  and  regular  in  distribution.  The 
translucent  spaces  (lunettes)  between  the  vessels  are  extensive.  Below,  the 
mesentery  is  streaked  with  fat.  The  veins,  which  had  a  distribution  similar 
to  the  arteries,  are  for  simplicity  omitted  from  this  and  from  the  subsequent 
drawings.  The  subject  from  which  the  specimen  was  taken  was  a  male  of  forty 
years,  with  rather  less  than  the  usual  amount  of  fat.  The  entire  length  of  the 
intestine  was  twenty-three  feet   (Monks). 


Fig.  154. — A  loop  of  intestine  at  six  feet.  As  compared  with  Fig.  153,  the 
gut  is  somewhat  smaller.  The  vascularity  of  the  intestine  and  mesentery  is 
less.  Secondary  loops  are  a  prominent  feature.  The  vasa  recta  are  smaller. 
The  lunettes  are  also  present,  but  are  not  so  large  as  in  Fig.  153.  The  subject 
was  a  male  of  about  thirty-five  years,  with  an  average  amount  of  fat.  The 
entire  length  of  the  intestine  was  twenty  feet  (Monks). 

380 


Fig.  155. — A  loop  of  intestine  at  nine  feet.  The  secondary  loops  are  large; 
the  vasa  recta  are  somewhat  irregular  and  shew  branches.  No  lunettes  are 
present,  and  the  mesentery  is  streaked  with  fat,  and  is,  therefore,  somewhat 
opaque.  The  specimen  was  taken  from  the  same  subject  which  furnished  Fig. 
153  (Monks). 


Fig.  156 . — A  loop  of  intestine  at  twelve  feet .  The  vessels  are  smaller.  The 
primary  loops  are  lost  in  the  fat,  but  secondary  and  even  tertiary  loops  are 
visible.  The  vasa  recta  are  shorter,  more  irregular,  and  branching.  The  speci- 
men came  from  the  same  subject  which  furnished  Figs.  153  and  155  (Monks). 


3S1 


Fig.  157. — A  loop  of  intestine  at  seventeen  feet.  The  mesentery  is  opaque, 
and  small  tabs  of  fat  begin  to  appear  along  the  mesenteric  border  of  the  gut. 
The  vessels  are  represented  b}^  a  somewhat  complicated  network,  and  are  seen 
with  difficulty  in  the  thick  fat  of  the  mesenter}^.  The  specimen  came  from  the 
subject  which  furnished  Figs.  153,  155,  and  156  (Monks). 


Fig.  15s. — A  loop  of  intestine  at  twenty  feet.  The  gut  appears  to  be  thick 
and  large.  The  mesentery  is  quite  fat  and  opaque,  and  large  and  niimerous 
fat  tabs  are  present.  The  vessels,  which  are  complicated,  are  seen  with  diffi- 
culty, and  are  represented  by  mere  grooves  in  the  fat.  The  subject  was  a  stout 
woman,  and  the  entire  length  of  the  gut  was  twenty-one  feet  (Monks). 

382 


INTESTINAL   LOCALISATION.  383 

time  getting  nearer  and  nearer  to  the  gut.  Opposite  the  lower 
part  of  the  gut  the  loops  generally  lose  their  characteristic  ap- 
pearance, and  are  represented  by  a  complicated  network.  Op- 
posite the  upper  part  of  the  intestine  the  vasa  recta  are  from 
three  to  five  centimetres  long,  when  the  loop  of  small  intestine  to 
which  they  run  is  lifted  up  so  as  to  put  them  gently  on  the  stretch. 
They  are  straight,  large,  and  regular,  and  rarely  give  off  branches 
in  the  mesentery.  In  the  lower  third  they  are  very  short,  being 
generally  less  than  one  centimetre  in  length.  Here  they  are  less 
straight,  smaller,  less  regular,  and  have  frequent  branches  in  the 
mesentery."* 

*  For  the  figures  which  are  here  reproduced  I  am  very  greatly  indebted 
to  the  courtesy  of  Dr.  G.  H.  Monks. 


CHAPTER  XXI. 
INTESTINAL  SUTURE. 

There  are  probably  no  pages  in  the  histor}'  of  surger}^  that 
are  so  grossly  encumbered  with  the  description  of  useless  methods 
of  work  as  those  dealing  with  the  subject  of  the  suture  of  in- 
testinal wounds.  Of  the  methods  which  have  been  advocated, 
volumes  might  be  written,  and  willing  and  patient  authors  have 
not  been  found  wanting.  It  is  true  that  there  has  been  a  con- 
stant and  laudable  striving  after  perfection,  but  the  steps  upon 
the  road  to  success  have  been  infinite  in  number,  and  they  have 
not  all  been  steps  in  a  forward  direction.  Even  at  the  present 
time  this  subject  is  not  free  from  the  incursions  of  the  eager 
inventor,  enthusiastic  as  to  the  claims  of  his  newest  contrivance, 
despite  the  fact  that  all  mechanical  aids  to  suture  are  tmnecessars' 
— ^in  that  one  word  may  be  summarised  all  that  can  be  said  of  them. 
I  do  not  venture  to  suggest  that  even  3^et  any  method  has  been 
advocated  that  will  win  universal  acceptance.  But  of  this  there 
can  be  no  question,  that  such  a  method,  when  established,  will 
of  necessity  combine  in  the  highest  degree  two  essential  princi- 
ples— simplicity  and  safety.  A  method  that  is  simple,  and 
therefore  readily  learnt,  applicable  to  all  forms  of  anastomosis, 
speedy  because  of  its  simplicity,  and  safe  because  of  all  its  at- 
tributes, is  the  only  one  that  is  destined  to  survive. 

The  following  suture  methods  possess  certain  definite  ad- 
vantages which  have  caused  them  to  be  practised  by  a  large 
number  of  surgeons — they  are  recognised,  that  is,  as  good 
methods. 

Lembert's  Suture. — This,  which  is  the  simplest  of  all  in- 
terrupted stitches,  is  one  that  every  surgeon  finds  it  necessary 
to  use  on  some  occasion.  The  needle,  bearing  a  suture  of  fine 
silk  or  thread,  is  passed  transversely  to  the  wound.     It  picks  up, 

384 


INTESTINAL    SUTURE.  385 

on  each  side,  all  the  coats  except  the  mucosa,  and  is  introduced 
about  a  quarter  of  an  inch,  or  rather  less,  from,  and  emerges 
about  a  line  from,  the  edge  of  the  wound,  on  one  side,  then 
passes  across  the  wound,  to  enter  on  the  opposite  side  at  a  point 
just  clear  of  the  cut  edge,  there  to  pass  in  the  wall  of  the  gut 
in  the  same  manner  as  on  the  opposite  side.  When  the  suture 
is  tied,  the  edges  of  the  wound  are  inverted  and  broad  surfaces 
of  peritoneum  on  each  side  of  the  wound  are  brought  into  con- 
tact. The  individual  sutures  lie  about  -J  inch  from  each  other. 
In  tying  the  stitches  it  is  impor- 
tant to  avoid  drawing  them  over- 
tight,  and  thereby  causing  a  risk 
of  strangulation  necrosis.  A  snug 
apposition  of  surface  is  all  that 
is  necessary  to  ensure  a  perfectly 
firm,  water-tight  junction.  When 
this  suture  is  continuous  and  not 
interrupted,  it  is  known  as  Dupuy- 
tren's  suture. 

The  width  of  the  fold  picked 
up  on  each  side  will  vary  accord- 
ing to  the  necessities  of  the  case. 
If  the  wound  be  small  and  the 
bowel-wall  healthy,  so  that  sutures 

are  well  held,  the  fold  need  be  but        pig.  i-g. Lemberf s  suture. 

small  and  the  inner  row  of  needle 

punctures  may  be  quite  close  to  the  edge  of  the  wound.  In 
other  instances,  as,  for  example,  in  the  perforation  of  a  duodenal 
or  typhoid  ulcer,  a  wider  fold  must  be  made,  and  greater  care 
must  be  exercised  in  the  introduction  of  the  needle,  since,  owing 
to  the  thickened  and  stiffened  wall  of  the  gut,  the  needle  will 
perhaps  cut  through,  or  the  stitch  will  fail  to  hold  when 
tightened. 

Halsted's   suture,    or  the   mattress   suture,   is   in  realit}'   so 
devised  that  each  separate  suture  is  the  equiA'alent  of  a  double 
VOL.  1—25 


386 


ABDOMINAL   OPERATIONS. 


Lembert  suture.  The  needle  having  passed  from  one  side  of 
the  wound  to  the  other  is  made  to  return,  so  that  the  two  ends 
of  the  suture  lie  upon  the  same  side  of  the  wound.     When  the 

stitch  is  tied,  there  is  no  risk 
of  undue  constriction  of  ves- 
sels, and  the  stitch  is  little 
likely  to  cut  through.  Broad 
peritoneal  surfaces  are 
brought  into  apposition.  The 
importance  of  the  inclusion 
within  the  suture  of  the  sub- 
mucosa  was  emphasised  by 
Professor  Halsted.  It  was 
claimed  for  this  suture  that 
it  is  so  safe  that  a  single  row 
is  all  that  is  necessary;  that 
the  tissues  are  less  constricted 
than  they  are  by  a  Lembert 's 
suture,  and  that  the  suture  does  not  so  readily  tear  out  when 
submitted  to  tension. 

Dupuytren's  Suture. — This  suture  is  similar  to  the  Lembert 
suture,  but  is  continuous,  not  interrupted.     After  the  first  suture 


Fie.    1 60. — Halsted's  suture. 


Fig.   161. — Dupuytren's  continuous  suture:    a  continuous  Lembert 's  suture;    it 

begins  on  the  left. 


is  introduced  it  is  tied,  and  the  suture  is  then  continued  from 
side  to  side  of  the  wound  to  the  opposite  end. 


INTESTINAL   SUTURE.  387 

Cushing's  Suture. — Hayward  W.  Gushing  (Trans.  Amer. 
Surg.  Assoc,  vol.  xvii,  1899)  has  described  a  suture  that  is  also  con- 
tinuous. The  needle,  on  each  occasion  that  it  is  introduced,  is 
passed  parallel  to  the  edge  of  the  wound,  and  not,  as  in  the  Lem- 
bert  or  Dupuytren  suture,  at  right  angles  to  it. 

All  the  sutures  above  described  are  passed  with  the  intention 
of  including  all  coats  of  the  bowel  with  the  exception  of  the 
mucosa.  The  layer  which  it  is  of  the  chiefest  importance  to 
secure,  in  order  that  the  suture  may  hold  well,  is  the  submucous 
coat.  This,  as  shewn  by  S.  D.  Gross  and  Halsted,  is  of  great 
strength  and  toughness,  and  will  bear  a  considerable  strain 
when  the  suture  is  tied. 

The  examination  of  specimens  removed  from  patients  upon 


^if-i/- 


y 

Fig.    162. — Cushing's  right-angled  continuous  suture. 

whom  the  Lembert  suture  has  been  used  shews,  without  doubt, 
that  the  ideal  passage  of  the  suture  is  not  always  achieved. 
In  not  a  few  instances  it  is  found  that  the  suture  at  some  point 
has  passed  into  or  through  the  mucosa.  The  fear  that  haunts 
the  surgeon's  mind  is  that  if  the  suture  should  penetrate  the 
mucosa,  a  track  for  the  escape  of  infected  contents  from  the 
lumen  of  the  bowel  is  open  to  the  peritoneal  cavity.  Theo- 
retically the  danger  exists,  but  in  practice  it  does  not  often 
prove  serious,  unless  the  perforation  occurs  at  the  point  where 
a  knot  is  tied,  and  then  leakage  is  very  likely  to  occur.  In  an 
interrupted  suture,  therefore,  which  perforates  all  the  coats  of  the 
bowel,  and  in  which  the  knot  is  tied  on  the  serosa,  there  are  the 


388  ABDOMINAL    OPER.\TIOXS. 

elements  of  disaster.  If,  however,  the  interrupted  suture  is 
tied  on  the  mucous  side,  it  is  found,  as  a  matter  of  unvaried  ex- 
perience, that  no  leakage  occurs,  or  rather  that  what  drainage 
or  "capillars^  attraction"  is  excited  by  the  suture,  is  towards 
the  lumen  of  the  gut,  and  not  towards  the  peritoneal  cavity. 
It  has  been  the  aim,  therefore,  of  mam-  operators  to  devise  a 
stitch  which,  passing  through  all  the  coats  on  both  sides  of  the 
wound,  may  be  tied  in  such  manner  that  all  the  knots  shall  He 
within  the  lumen  of  the  gut.  The  advantages  of  such  a  stitch 
are  obvious:  a  firm,  accurate,  and  even  hold  is  obtained  upon 
the  gut ;  the  A-essels  in  the  cut  edge  of  the  gut  are  controlled 
when  the  stitch  is  made  continuous,  and  a  rapid  introduction 
is  easity  accompHshed. 

The  method  which,  among  modem  operations,  was  the 
pioneer  of  all  those  planning  to  effect  union  by  through-and- 
through  sutures,  was  suggested  b}'  Alaunsell  ("International 
Jour,  of  the  Medical  Sciences,"  vol.  ciii,  1892,  p.  245).  The  fol- 
lowing is  the  description  given  b}"  him: 

"Having  cut  oft"  the  cancerous,  gangrenous,  or  injured  por- 
tion of  the  intestine,  bring  together  both  ends  of  the  bowel  with 
two  temporar}^  sutures  passed  through  all  the  coats  of  the  in- 
testine. The  long  ends  of  these  sutures  are  left  intact.  One 
is  placed  at  the  mesenteric  attachment  of  the  gut  and  the  other 
(exactly  opposite)  at  the  most  distant  portion  of  the  bowel  from 
the  mesentery. 

"These  temporary  sutures  are  very  important.  They  se- 
cure the  complete  peritoneal  covering  of  the  mesenteric  at- 
tachment of  both  segments  of  the  gut,  help  to  maintain  the 
proper  relative  position  and  accurate  co-adaptation  of  the  two 
cut  ends,  and  facilitate  their  subsequent  invagination  through 
the  opening  made  in  the  larger  segment  of  gut . 

"When  enterectomy  is  performed  for  gangrene  or  injury, 
the  lower  or  distal  segment  of  the  bowel  is  generally  the  largest; 
but  where  the  operation  is  performed  for  stricture,  cancer,  or 
tumour  pressing  on  or  constricting  the  lumen  of  the  gut,  the 
upper  or  proximal  portion  is  often  much  larger  than  the  lower. 

"If  vou  examine  the  gut  in  a  living  animal,  vou  will  find 


INTESTINAL   SUTURE. 


389 


that  the  blood-vessels  pass  into  it  from  the  mesenteric  attach- 
ment. These  divide  and  subdivide  until  they  are  lost  in  an 
invisible  anastomosis  in  that  portion  of  the  intestine  more  dis- 
tant from  the  mesentery. 

"I  propose  to  make  an  opening  here  in  the  larger  segment 
of  the  gut,  through  which  the  invaginated  ends  of  the  divided 


Fig.   163. — Maunsell's  operation. 

bowel  may  be  dragged  by  the  long  ends  of  the  temporary  sutures, 
and  when  they  are  accurately  sewn  together  all  around,  they  may 
be  pulled  back  into  their  normal  position . 


Fig.    164. — Maunsell's  operation. 


"The  edges  of  the  longitudinal  slit  made  in  the  bowel,  which 
begins  about  an  inch  from  its  transverse  section,  should  be  well 
turned  in  and  brought  together  with  a  continuous  suture 
passed  through  the  peritoneal  and  muscular  coats  only.  It  is  a 
well-ascertained  fact  that  a  slight  longitudinal    contraction    of 


390  ABDOMINAL   OPERATIONS. 

the  lumen  of  the  bowel  does  not  interfere  with  its  physiological 
functions. 

"  By  this  simple  device  the  perfect  union  by  suture  of  a  com- 
plete transverse  section  of  the  bowel,  with  its  circumferential 
peritoneal  surfaces  in  exact  position  and  all  the  knots  of  the 
sutures  on  the  inside,  can  be  accomplished. 

"  From  an  examination  of  the  annexed  figures  it  may  be  seen 
that  the  peritoneal  surfaces  are  in  accurate  juxtaposition  all 
around.  While  an  assistant  holds  the  ends  of  the  temporary 
sutures,  the  surgeon  passes  a  long,  fine,  straight  needle,  armed 
with  a  stout  horse-hair  or  very  fine  silkworm-gut  through  both 
sides  of  the  bowel,  taking  a  good  grip  (quarter  of  an  inch)  of 
all  the  coats.  The  suture  is  then  hooked  up  from  the  centre  of 
the  invaginated  gut,  divided,  and  tied  on  both  sides.      In  this 


■<01t 


K  ^'^' 


Fig.   165. — Maunsell's  operation. 

way  twenty  sutures  can  be  placed  rapidly  in  position  with  ten 
passages  of  the  needle.  The  temporary  sutures  are  now  cut  off 
short,  and  the  sutured  ends  of  the  bowel  painted  with  Wolfler's 
mixture  of  alcohol,  glycerin,  and  colophony,  and  blown  over 
with  iodoform — the  same  that  he  applies  to  the  surface  of  the 
raw  stump  after  removal  of  the  tongue.  The  bowel  is  then 
pulled  back.  The  longitudinal  slit  in  the  gut  is  well  turned  in 
and  closed  with  a  continuous  suture  and  painted  with  Wolfler's 
mixture  and  iodoform  powder." 

In  actual  practice,  therefore,  Maunsell  was  content  to  rely 
upon  a  single  row  of  sutures  penetrating  all  the  coats  of  the 
bowel.  Alany  surgeons,  however,  being  sceptical  as  to  the 
security  from  leakage  with  one  layer  of  stitches  only,  added 
an   outer  laver  of   Lembert   sutures.     One   of  the  further  ob- 


INTESTINAL   SUTURE.  39 1 

jections  to  Maunsell's  method  was  the  possible  formation  of 
a  diaphragm  if  an  outer  layer  of  Lembert  sutures  was  used. 
In  their  experimental  work,  Edmunds  and  Ballance  found  that 
no  diaphragm  whatever  was  formed.  Maunsell,  by  his  work, 
shewed  conclusively  that  a  perfect  suture-line  resulted  from 
the  use  of  a  single  layer  of  stitches  passing  through  all  the  coats. 
His  method,  however,  in  that  it  involved  the  making  of  a  special 
longitudinal  opening  into  the  gut,  was  found  to  be  unneces- 
sarily tedious  and  complex,  and  efforts  were,  therefore,  directed 
to  such  a  modification  of  the  method  as  would  permit  the  prin- 
ciple to  be  retained  while  the  steps  to  attain  it  were  simplified. 
Dr.  Gregory  Connell  and  Dr.  Wiggin  have  both  succeeded 
in  perfecting  a  simple  and  effective  method.  Connell's  method 
is,  it  seems  to  me,  one  of  the  most  satisfactory  methods  of 
suture  in  use  at  the  present  time.  It  is  easy  to  learn,  simple, 
rapidly  performed,  and  the  line  of  union  is  firm  and  free 
from  any  chance  of  leakage.  The  only  difficulty  that  could 
possibly  be  experienced  in  its  use  is  that  which  arises  at  the 
time  of  tying  the  final  stitch.  A  very  little  practice  makes 
this  easy.  The  following  description  is  given  by  Dr.  Gregory 
Connell  in  "American  Medicine,"  vol.  v,  January,  1903,  p.  135. 
1  am  greatly  indebted  to  him  for  the  excellent  illustrations  he 
has  kindly  sent  to  me,  which  are  here  reproduced. 

"In  using  the  interrupted  suture,  the  first  stitch  should  be 
taken  at  the  mesenteric  attachment.  This  stitch  is  of  the 
greatest  importance  on  account  of  the  separation  of  the  serous 
covering  of  the  bowel  at  this  point,  and  great  care  should  be 
exercised  in  securing  a  perfect  serous  approximation  at  this 
point.  In  order  to  do  this  in  the  most  satisfactory  manner 
a  stitch  should  be  introduced  as  follows :  The  needle  is  made 
to  enter  the  bowel- wall  of  one  cut  end  from  the  lumen,  per- 
forate all  coats,  and  pass  through  the  serosa  of  one  side  of  the 
triangular  space  formed  by  the  separation  of  the  serous  coats; 
then  on,  over  and  through  the  serosa  of  the  opposite  cut  end, 
at  the  same  relative  point,  side  of  the  triangular  space,  then 


392 


ABDOMINAL   OPERATIONS. 


Fig.   1 66. — Connell's  suture. 


Fig.   167. — Connell's  suture  continuec 


INTESTINAL    SUTURE.  393 

on  through  the  wall  into  the  lumen.     This  completes  one-half 
of  the  stitch,  and  is  made  with  one  movement  of  the  needle. 

"The  needle  is  next  reversed,  and  a  distance  of  about  ^  of 
an  inch  (3  mm.)  is  made  to  repeat  the  steps  in  the  opposite 
direction — i.  e.,  entering  the  mucosa  of  the  second  cut  end, 
passing  through  all  coats  of  the  bowel-wall,  including  the  serosa 
of  the  triangular  space,  and  then  through  the  serosa  of  the  tri- 
angular space  of  the  first  cut  end,  on  through  the  wall  into  its 
lumen,  where  the  needle  end  and  the  free  end  of  the  suture 


Fig.   168. — Connell's  suture  continued. 

are  tied  in  a  knot  on  the  mucosa.  This  stitch,  which  acts 
similar  to  a  brad,  absolutely  secures  a  perfect  serous  approxima- 
tion at  this  point,  which  is  considered  by  all  to  be  the  most 
difficult  portion  of  an  enterorrhaphy. 

"The  remainder  of  the  union  is  closed  by  stitches  exactly 
similar  to  this  first  stitch.  The  cut  ends  are  held  in  proper 
position  by  any  convenient  means,  such  as  the  Lee  holder, 
the  Allis  tenaculum  forceps,  or  suspending  loops  of  thread ;  but 
the  best  method  in  my  experience  is  the  plan  of  introducing 


394  ABDOMINAL   OPERATIONS. 

a  stitch,  such  as  are  the  other  stitches,  at  a  conveniently  dis- 
tant point,  and  leaving  the  ends  of  this  stitch  long,  to  be  held 
by  an  assistant  while  the  intervening  stitches  are  being  in- 
serted. 

"This  method  has  the  advantage  of  consuming  no  additional 
time,  for  when  the  union  is  completed  up  to  this  stitch  and  the 
long  ends  are  of  no  farther  use,  they  are  cut  away,  leaving  the 
stitch  itself  in  place.  This  method,  which  I  described  in  1901, 
has  been  adopted  by  Dr.  Wiggin  in  the  description  of  his  method 
published  in  1902. 

"  With  the  ends  thus  held  in  proper  position  the  introduction 
of  the  stitches  is  a  very  simple  matter — merely  one  passage 
of  the  needle  through  all  coats  of  both  cut  ends,  and  then  at  a 
distance  of  about  -|-  of  an  inch  (3  mm.)  the  same  process  in  the 
opposite  direction,  and,  finally,  the  tying  of  the  knot  upon  the 
mucosa  at  one  side  of  the  seam. 

"This  is  repeated  till  all  but  a  small  portion  of  the  union 
is  completed.  Owing  to  the  fact  that  it  is  impossible  to  place 
this  last  portion  of  the  cut  ends  in  the  same  relative  position 
that  we  placed  the  first  part — i.  <?.,  seroserous  apposition,  it  is 
therefore  necessary,  in  order  to  introduce  the  same  variety  of 
suture,  to  proceed  somewhat  differently. 

"In  order  to  place  the  last  stitch  and  knot  in  exactly  the 
same  relative  position  as  the  first  ones,  we  proceed  in  this  manner : 

"The  needle  enters  the  gut -wall  from  the  lumen,  passes 
through  all  coats,  and  emerges  from  the  serosa  of  one  side.  It 
is  then  made  to  cross  over  to  the  opposite  wound  margin,  and, 
entering  the  serosa,  passes  through  all  the  coats  into  the  lumen 
of  this  side.  The  needle  is  then  turned  upon  itself  and  made  to 
retrace  its  steps  at  about  \  of  an  inch  (3  mm.)  distant,  passing 
from  the  lumen  through  all  coats,  emerging  from  the  serosa; 
then  over  to  the  opposite  side  and  entering  through  the  serosa, 
and  finally  ending  in  the  lumen  of  the  cut  end  at  which  it  began. 

' '  Now  the  two  ends  of  the  thread  which  are  to  make  the  knot 
are  side  by  side,  emerging  from  the  mucosa  into  the  lumen,  and 
then  extending  from  the  ununited  part  of  the  enterorrhaphy  out 
of  the  body.  The  needle,  in  introducing  this  stitch,  has  passed 
through  the  cut  ends  in  exactly  the  same  order  as  it  did  when 
inserting  the  stitches  in  the  earlier  part  of  the  operation  when 
the  cut  ends  were  held  in  seroserous  apposition — /.  e.,  mucosa,  sub- 


INTESTINAL    SUTURE. 


395 


mucosa,  muscularis,  and  serosa,  then  immediately  on  into  the 
other  end  cut  through  the  serosa,  muscularis,  submucosa,  and 
the  mucosa,  and  then  this  order  repeated  in  the  opposite  direc- 
tion ^  of  an  inch  (3  mm.)  away. 

"The  needle  and  the  free  end  of  the  suture  now  hang  side 
by  side  from  the  mucosa,  and  in  order  that  they  be  tied  in  a 
firm  knot,  proceed  as  follows: 

"At  a  point  in  the  line  of  union,  about  opposite  this  last 
and  still  untied  stitch,  a  threaded  needle  is  inserted,  eye  first, 


Fig.   169. — Connell's  suture  continued. 


between  two  of  the  previously  inserted  and  tied  stitches.  The 
needle  is  passed  between  the  apposed  serous  surfaces  into  the 
lumen. 

"  By  passing  the  needle  still  farther  onward  it  is  made  to 
present  at  the  location  of  the  last  stitch,  where  the  ends  of  the 
suture  still  protrude,  and  where  the  surfaces  are  not  united.  By 
sHghtly  withdrawing  the  threaded  needle  a  loop  is  formed  with 
its  thread;  into  this  loop  are  placed  the  two  free  ends  of  the 
last  stitch  which    is   to    be  tied.     By  withdrawing  the    needle 


396 


ABDOMINAL   OPERATIONS. 


Fig.    170. — Connell's  suture  continued. 


Fig.   171. — Connell's  suture  continued. 


INTESTINAL   SUTURE. 


397 


and  in  its  loop  the  stitch  ends,  these  ends  will  be  made  to  pre- 
sent upon  the  peritoneal  aspect  of  the  bowel  on  the  opposite 
side,  between  two  of  the  previously  inserted  and  tied  stitches— 
i.  e.,  at  the  point  where  the  threaded  needle  was  inserted.  Slight 
traction  upon  these  ends  will  cause  the  remaining  portion  of 
the  line  of  union  to  become  inverted,  and  seroserous  approxima- 
tion will  obtain  entirely  around  the  site  of  suture.  Upon  greater 
traction  the  bowel  will  become  flattened,  bringing  the  mucous 
membrane  upon  which  the  last  knot  is  to  be  located  into  in- 
timate relationship  with  the  line  of  suture  at   the  point  where 


Fie. 


17: 


-Connell's  suture  continued. 


the  free  ends  protrude.  The  knot  is  tied  with  the  bowel  m 
this  flattened  position,  thus  avoiding  the  occurrence  of  any 
slack.  While  still  retaining  the  tension  and  the  flattened  posi- 
tion, the  ends  of  the  knot  are  cut  off  short,  so  preventing  any 
long  free  ends  in  the  lumen.  Upon  allowing  the  bowel  to  as- 
sume its  normal  contour, — that  of  a  cylinder, — ^the  knot  will 
slip  between  the  already  tied  stitches  into  the  lumen,  and  as  it  is 
attached  to  the  mucosa  of  the  opposite  pole  of  the  diameter  of 
the  gut,  it  goes  with  that  portion  of  the  bowel-wall." 

The  Connell  stitch  here  described  is,  therefore,  an  interrupted 
stitch.     In  the  same  paper,  however,  Dr.  Connell  writes : 


398  ABDOMINAL   OPERATIONS. 

"As  stated  on  previous  occasions,  either  the  interrupted 
or  the  continuous  suture  may  be  employed,  the  choice  depend- 
ing upon  the  teaching  or  the  experience  that  the  operator  has 
had.  This  method  may  be  applied  equally  well  in  circular  en- 
terorrhaphy,  lateral  anastomosis,  pylorectomy,  pyloroplasty, 
gastro-enterostomy,  and  in  incised  wounds  of  the  intestine 
or  stomach, — ia  fact,  under  any  conditions  where  the  ordinary 
sutures  may  be  employed." 


Fig.    173. — Connell's  suture  continued. 

Though  interrupted  sutures  are,  in  certain  stages  of  work, 
absolutely  indispensable, — for  example,  in  reinforcing  at  a 
weak  spot  or  in  securing  a  vessel  in  a  cut  edge  of  the  gut, — yet 
I  am  convinced  that  the  continuous  suture  is  very  decidedly 
to  be  preferred.  The  continuous  suture  is  easily  and  rapidly 
introduced — very  much  more  rapidly  than  the  interrupted 
stitch.  In  the  latter,  the  needle  has  to  be  received  from  an 
assistant,  to  be  passed,  the  knot  to  be  tied,  and  the  ends  to  be 
cut  for  each  separate  stitch;  such  a  series  of  separate  move- 
ments  necessarily  involves  a  waste   of  time.     The   continuous 


INTESTINAL   SUTURE.  399 

suture  is  tightened  to  exactly  the  right  degree  without  any 
difficulty.  It  acts,  when  embracing  all  the  coats,  as  a  haemo- 
static, making  the  separate  ligation  of  bleeding  points  unneces- 
sary. It  produces,  when  used  as  a  Dupuytren's  suture,  very 
accurate  and  equal  apposition  of  serous  surfaces  along  the 
entire  length  of  the  Avound.  It  has  never,  in  my  hands,  caused 
sloughing  of  the  cut  edges  of  the  wound  from  constriction  of 
the  blood-supply,  and  I  am,  therefore,  compelled  to  think  that 
this  fear,  so  often  expressed,  is  but  a  legacy  from  an  earlier  age. 
The  objections  which  have  been  raised  to  the  continuous  suture 
are — 

(a)  If  one  part  of  it  becomes  loose,  the  whole  is  liable  to  be- 
come insecure.  When  properly  introduced,  in  the  manner  to  be 
presently  described,  there  is  no  fear  whatever  of  any  part  of  the 
suture  working  loose,  nor,  on  the  other  hand,  of  any  part  of  the 
suture  causing  puckering  by  being  drawn  overtight.  An  even 
tension  all  along  the  line  is  secured  by  unconscious  effort  after 
a  little  practice. 

(b)  If  the  bowel  contract,  the  whole  suture  may  become 
loosened  and  the  wound  gape.  This  might  perhaps  be  true  of 
a  continuous  serous  stitch  unsupported,  but  if  a  firm  hold 
of  all  the  coats  is  obtained,  the  fear  of  loosening  is  purely 
visionary. 

(c)  A  considerable  length  of  ligature  material  is  left  in  the 
coats  of  the  intestine.  It  has  been  shewn,  as  the  result  of  ex- 
perimental work  and  of  observation  upon  man,  that  a  stitch 
which  perforates  the  mucosa  will  by  degrees  become  loosened, 
and  eventually  pass  entirely  into  the  lumen  of  the  gut.  A 
stitch  including  the  serous  and  muscular  coats  only  will  re- 
main imbedded  in  the  coats  of  the  gut  for  months  or  years,  but 
may  also,  probably  because  of  a  too  deep  penetration  of  the  wall, 
eventually  be  discharged  into  the  lumen.  This,  I  believe, 
occurs  in  the  very  great  majority  of  instances.  On  several  occa- 
sions I  have  had  the  opportunity  of  examining  an  intestinal  or 
gastro-intestinal  anastomosis  many  months  after  the  operation, 
and  I  have,  in  almost  all,  found  that  no  trace  of  the  original 
suture  of  silk  or  thread  remained.  The  objection  to  the  length 
of  the  suture  cannot  be  upheld. 


400  ABDOMINAL   OPERATIONS. 

These  supposed  disadvantages  of  the  continuous  suture  have 
no  foundation  in  experience.  It  is  true  that  the  continuous 
suture  can  cause  harm  if  improperly  applied,  but  the  same  ob- 
jection holds  good  to  all  forms  of  suture,  and,  indeed,  to  all 
surgical  methods.  The  vice  then  is  not  in  the  suture,  but  in  the 
wrongful  application  of  it.  It  is  perfectly  easy  to  learn  exactly 
how  to  introduce  the  stitch  and  the  degree  of  tension  that  is  the 
safest. 

Of  all  methods  of  intestinal  suture,  it  would  seem  to  me  that 
one  is  unquestionably  the  best  for  general  use.  It  is  the  method 
in  which  two  sutures,  both  continuous,  are  used.  The  inner 
suture  includes  all  the  coats,  the  outer,  the  serous,  muscular,  and 
subserous  coats  only.  The  inner  stitch  secures  good  and  ef- 
ficient approximation,  a  firm  apposition,  in  fact,  and  acts  per- 
fectly in  controlling  the  bleeding  from  the  cut  edge  of  the  gut. 
The  outer  suture  supports  the  inner  and  ensures  a  sufficient 
apposition  of  serous  surfaces. 

It  might  be  feared  that  such  a  stitch  would  cause  an  inversion 
of  the  suture-Hne  to  a  degree  sufficient  to  give  rise  to  a  spur  or 
diaphragm.  In  practice,  however,  it  is  found  that  the  fear  is  not 
justified.  The  little  thickening  at  the  suture-line,  though  plainly 
seen  within  the  first  few  da^'S,  gradually  dwindles  until  a  normal 
appearance  remains. 

This  method  of  suture  is  applicable  to  all  forms  of  intestinal 
anastomosis,  I  have  used  it  in  gastro-enterostomy,  after  in- 
testinal resection  in  the  small  and  large  intestines,  and  after 
excision  of  the  caecum,  both  for  lateral  and  for  end-to-end  anas- 
tomoses. Its  universal  applicability  is,  of  course,  greatl}^  in  its 
favour,  for  a  surgeon  can  the  more  speedily  complete  a  suture  to 
which  he  is  accustomed.  It  is  simple  and  safe.  I  have  used  it 
in  one  part  or  another  over  500  times,  and  the  only  occasion 
upon  which  the  suture-hne  has  leaked  was  in  a  case  of  end-to-end 
ileocolostomy,  where  a  small  faecal  fistula  formed  and  remained 
open  for  about  ten  days.    When  the  suture  is  completed,  the  accu- 


INTESTINAL   SUTURE. 


401 


rate  apposition  ensured  by  the  inner  suture  prevents  leakage 
until  such  time  as  a  perfect  serous  union  is  completed. 

The  suture  is  applied  in  the  following  manner:  The  two  open- 
ings, whether  terminal  or  lateral,  that  are  to  be  united  are  placed 


,0 


Fig.  174.  —  Intestinal  suture  for 
end-to-end  or  lateral  anastomosis. 
The  cut  ends  are  clamped  and  the 
outer  seromuscular  suture  is  com- 
menced. 


Fig  175. — The  seromuscular  su- 
ture in  its  first  portion  is  completed. 
The  inner  suture  which  embraces 
all  the  coats  is  begun.  Note  espe- 
cialh-  the  manner  in  which  the  gap 
in  the  mesentery  is  secured.  The 
needle  enters  at  the  point,  A,  and 
passes  at  the  direction  of  the  arrow. 


side  by  side,  the  bowel  in  which  they  are,  being  held  by  a  clamp. 
The  outer  or  serous  stitch  is  now  commenced  at  the  part  of  the 
gut  farthest  from  the  operator,  and  an  ordinary  Dupuytren's 
stitch  is  used,  being  continued  around  the  posterior  margin  of  the 
opening  until  the  point  nearest  the  operator  is  reached,  when  the 


VOL.  I — 26 


^02  ABDOMINAL   OPERATIONS. 

needle  is  laid  aside.  The  needle,  on  each  occasion  that  it  is 
passed,  picks  up  only  the  serous  and  muscular  and  in  part  the 
submucous  coats.  At  least  that  is  the  intention  of  the  operator, 
but  I  think  it  not  at  all  unlikety  that  sometimes  the  needle  may 
penetrate  deeper  than  this,  and  include  all  the  coats  of  the  bowel. 
If  this  is  done  no  harm  comes  from  it. 

The  second  inner  stitch  is  now  started.     The  needle  is  passed 

through  all  the  walls  of  the  gut, 
which  lies  to  the  operator's  right, 
at  the  point  of  the  bowel  which 
is  farthest  from  him.  After 
passing  from  the  mucous  to  the 
serous  coat,  it  is  withdrawn  and 
then  passed  through  the  oppos- 
ing gut  from  the  serous  surface 
to  the  mucous,  and  the  suture  is 
tied,  so  that  this  knot  lies  within 
the  lumen  of  the  bowel.  If  an 
end-to-end  anastomosis  is  being 
performed,  the  first  stitch  is  taken 
in  the  manner  shewn  in  the 
annexed  drawing.  The  end  of  the 
suture  is  left  long  and  is  held  by  a 
clip.  The  stitch  is  now  passed 
along  the  hinder  margins  of  the 
openings  to  be  united,  until  the 
part  of  the  gut  nearest  to  the 
operator  is  reached.  Half  of  the 
suture  line  is  then  completed. 
The  suture  now  returns  to  the  point  from  which  it  started 
along  the  anterior  margin,  picking  up  all  the  coats  in  the  same 
manner  until  the  original  end  of  the  suture  is  reached,  when  the 
stitch  is  knotted  and  cut  short.  If  it  is  desired  to  infold  the  mucous 
membrane,  which  is  better  though  not  necessary,  the  anterior  layer 
of  this  inner  suture  is  passed  in  a  different  manner.     The  principle 


Fig.  1 76. — The  first  portion  of  the 
inner  suture  is  almost  complete. 
This  is  the  point  at  which  the  char- 
acter of  the  stitch  changes,  as  shewn 
in  next  illustration. 


INTESTINAL   SUTURE. 


403 


to  be  then  observed  is  to  pass  the  needle  twice  consecutively 
through  each  side  of  the  wound  so  as  always  to  leave  a  loop  on  the 
mucous  surface.     On  each  wound  edge  the  needle  then  passes 

from  serous  to  mucous,  and  at  once 
■'  '^  back  from  mucous  to  serous   sur- 

face.    As  the  stitch  is  drawn  tight 


Fig.  177. — The  inner  through- 
and-through  suture  is  changed 
here.  The  needle  having  reached 
the  mucous  surface  of  the  left 
opening  is  passed  in  on  this  side 
again  from  mucous  to  serous  sur- 
face. Then  on  the  right  side  it 
passes  from  serous  to  mucous  and 
back  from  mucous  to  serous  sur- 
faces, so  that  a  loop  is  always  left 
on  the  mucosa. 


Fig.  1 78. — The  inner  suture  continued. 
Note  the  loops  always  on  the  mucosa. 
When  the  stitch  is  tightened  the  cut  edge 
of  the  mucosa  is  infolded  and  serous  appo- 
sition secured. 


the  mucosa  becomes  infolded.    The 

character  of  the  suture  stitch,  from 

the    ordinary    continuous    running 

stitch  to  the  "  mucosa-loop  "  stitch, 

is  changed  when  the  first  half  of  it  is  almost  complete  at  the  point 

shewn  in  the  figure.     The  needle  is  introduced  at  points  about  -^-^ 

or  yVof  an  inch  apart,  and  the  stitch  is  tightened  to  the  necessary 


404 


ABDOMINAL   OPERATIONS. 


degree  b)^  holding  it  taut  for  the  better  demonstration  of  the  next 
point  for  the  introduction  of  the  needle.  When  this  stitch  is  com- 
plete, the  clamps  are  generally  removed.  The  outer  serous  stitch  is 
now  continued ;  the  needle  which  was  temporarity  laid  aside  being 

again  picked  up  and  the 
suture  continued  around  the 
anterior  margin  of  the  first 
suture  until  the  point  is 
reached  from  which  it 
started,  when  the  suture  is 
tied  and  cut  short.  The 
needle  which  it  will  be  found 
most  convenient  to  use  is 
the  ordinary  curved  intes- 
tinal needle;  for  suture 
material  I  prefer  celluloid 
thread.  The  stitch  is  not 
interrupted  or  knotted  at 
any  point. 

Such  are  the  chief  forms 
of  intestinal  suture,  and  b}^ 
the  help  of  these  all  forms 
of  intestinal  repair  or  anastomosis  can  be  safely  accom- 
plished. Of  them  all,  I  believe  that  the  Connell  stitch  and 
the  stitch  just  described,  in  which  two  layers  of  sutures  are  used, 
are  those  which  possess  undoubted  advantages  over  all  others. 
They  are,  in  my  opinion,  the  two  sutures  upon  which  surgeons 
of  the  present  and  of  the  immediate  future  will  find  it  safest  to 
depend.  The  use  of  mechanical  appliances  is  no  longer  neces- 
sary; these  have  played  their  part— a  most  important  part,  I 
gratefully  admit — in  the  development  of  surgical  work,  and  it  is 
now  time  that  their  use  should  be  abandoned.  The}'-  have  been 
useful,  nay,  indispensable,  steps  on  the  march  of  progress.  To 
Murphy,  above  all  other  surgeons, — for  his  instrument  is  one  of 
the  most  ingenious  mechanical  contrivances  ever  invented, — we 


Fig.  179. — The  inner  suture  completed;  the 
return  half  of  the  outer  suture  begun. 


INTESTINAL    SUTURE. 


405 


Fit 


iSo. — The  inner  suture  completed;    the 
outer  one  (seromuscular)  resumed. 


should  gratefully  acknowledge  the  debt  we  owe.  Without  the 
knowledge  that  work  with  his  button  has  given  to  us  the  surgery 
of  the  stomach  and  intes- 
tines would  never  have 
reached  its  present  stage. 
The  weightiest  argu- 
ment against  all  mechan- 
ical aids  to  anastomosis  is 
this — they  are  unneces- 
sary. By  their  aid  we  do 
not  accomplish  anything 
that  cannot  be  accom- 
plished with  equal  rapid- 
ity and  with  greater 
safety  by  the  simple 
suture.  We  have  noth- 
ing to  gain  from  their  use,  and  we  risk  much  by  leaving  behind 
something  which  ma}^  be,  and  often  has  been,  the  direct  cause 

of  danger  and  of  death. 
The  day  of  mechanical 
aids  is  over.  The  buttons 
and  the  bobbins,  the  elas- 
tic ligatures  and  the  for- 
ceps of  many  forms,  have 
now  no  more  than  an 
historical  interest. 

The  method  of  end- 
to-end  anastomosis  by  in- 
vagination has  been  per- 
fected by  C.  L.  Gibson. 
In  certain  circumstances 
the  method  offers  advan- 
tages over  any  other,  and  is  especially  applicable  when  the  pelvic 
colon  has  to  be  united  to  the  rectum.     ("Trans.  Amer.   Surg. 
Assoc,"  1910,  xxxviii,  262.) 


Fig.  iSi. — The  two  sutures  complete;  the  linal 
knot  ready  for  tying. 


CHAPTER  XXII. 
ENTEROTOMY  AND  ENTEROSTOMY. 

ENTEROTOMY. 

By  the  term  enterotomy  is  understood  the  opening  of  the 
intestine  for  the  purpose  of  immediate  drainage  or  for  explora- 
tion, followed  by  the  closure  of  the  wound.  Enterotomy  is  to 
be  distinguished  from  enterostomy,  in  which  the  opening  in  the 
intestine  is  fixed  to  the  abdominal  wall  in  such  manner  as  to 
ensure  continuous  drainage  from  the  bowel. 

The  operation  of  enterotomy  is  most  frequenth"  practised  in 
cases  of  acute  intestinal  obstruction.  It  is  also,  though  rarely, 
necessary,  in  cases  of  polypus  of  the  intestine,  or  for  the  removal 
of  a  foreign  body,  such  as  a  gall-stone.  Enterotomy  should  be 
looked  upon  as  an  almost  essential  feature  in  cases  of  acute  in- 
testinal obstruction.     If  the  distension  of  the  intestine  above 

St 
the  obstruction  is  considerable  or  of  comparatively  long  stand- 
ing, the  needed  relief  to  the  patient  is  not  afforded  by  the  mere 
act  of  freeing  the  constricted  spot.  The  mechanical  impediment 
to  the  onward  flow  of  intestinal  contents  is  not  the  cause  of 
the  serious  condition  of  the  patient.  It  is  the  overloading, 
distension,  and  the  ulceration  of  the  gut  above  the  block,  to- 
gether with  the  absorption  of  contents  whose  bacterial  viru- 
lence is  greatly  increased,  which  call  for  instant  relief.  No 
operation  for  acute  obstruction  can  be  considered  complete  which 
leaves  an  intestine,  whose  function  it  is  to  absorb,  overdistended 
by  contents  of  an  offensive  and  poisonous  nature.  To  empty 
the  bowel  of  its  fseculent  contents  is  not  to  add  a  danger  to  the 
operation  by  reason  of  the  opening  and  subsequent  suture,  but 
to  remove,  at  the  expense  of  a  trifling  expenditure  of  time, 
that  condition  which  makes   most   speedily  for  failure. 

406 


ENTEROTOMY  AND  ENTEROSTOMY.  407 

In  a  case  of  acute  obstruction  the  operation  is  performed  in 
the  following  manner : 

The  abdomen  is  opened,  the  point  of  ensnaring  located,  and 
the  gut  made  free.  The  details  of  this  procedure  will  be  sub- 
sequently considered.  The  bowel  which  had  been  constricted 
is  brought  up  to  the  surface  and  examined.  A  point  about  ten 
inches  above  the  site  of  the  constriction  is  chosen  for  the  in- 
cision. It  is  desirable  not  to  select  a  point  nearer  than  this, 
because  of  the  probable  damage  to  the  bowel  within  the  few 
inches  immediately  above  the  obstruction.  A  loop,  having  been 
drawn  out  of  the  abdomen,  is  temporarily  emptied  and  clamped 
by  the  fingers  of  an  assistant.  A  longitudinal  incision  about  one 
inch  in  length  is  then  made  in  the  bowel  at  the  part  most  distant 
from  the  mesentery.     The  edges  of  this  incision  are  seized  and 


li 


Fig.  182. — The  author's  tube  for  use  in  intestinal  obstruction. 

gently  held  with  the  finest  French  vulsella.  The  lower  portion 
of  the  distended  bowel — that  between  the  site  of  the  obstruction 
and  the  incision — is  now  emptied.  Two  fingers  are  placed  one 
on  each  side  of  the  intestine,  and  the  contents  are  "milked" 
upwards  and  emptied  through  the  incision,  the  lips  of  which  are 
held  apart  by  the  vulsella.  A  glass  tube  (a  Bantock's  tube 
does  very  well)  about  six  to  eight  inches  in  length,  to  the  outer 
end  of  which  a  large  drainage-tube  is  attached,  is  now  gently  in- 
troduced into  the  opening  in  the  gut  and  pushed  gradually  up- 
wards for  three  or  four  inches.  The  vulsella  are  now  removed 
from  the  edges  of  the  incision,  and  with  a  piece  of  gauze  the  bowel 
is  drawn  on  the  glass  tube  to  within  about  an  inch  of  the  end  to 
which  the  mbber  tube  is  attached.  At  this  point  the  bowel  is 
held  firm  by  an  assistant,  who  wraps  a  piece  of  gauze,  wrung  out 
of  hot  sterile  salt  solution,  around  the  tube  and  gut  together. 


408  ABDOMINAL   OPERATIONS. 

Leakage  by  the  side  of  the  tube  is  in  this  way  avoided.  The 
surgeon  now  draws  more  and  more  of  the  intestine  on  to  the 
tube,  and  as  this  is  done,  the  bowel  so  drawn  down  empties  its 
offensive  contents  through  the  rubber  tube  into  a  receptacle 
held  for  the  purpose.  It  will  be  found  that  upon  a  tube  6  inches 
in  length  eight  or  ten  feet  of  intestine  can  readily  be  drawn. 
This  manoeuvre  must  be  carried  out  slowly  and  with  great  care. 
It  is  essential  that  the  intestine  shall  be  pulled  on  to  the  tube 
little  by  little.  The  tube  itself  must  not  be  pushed  into  the  bowel, 
but  the  bowel  drawn  over  and  along  it.  Time  must  be  allowed 
for  the  perfect  emptying  of  the  bowel,  and  any  damage  to  the 


Fig.  183. — The  bowel  being  pulled  gently  along  the  tube.     The  tube  must  not 
be  pushed  into  the  intestine. 


bowel  by  the  tube  m.ust  be  diligently  avoided.  When  as  much 
of  the  bowel  as  possible  has  been  drawn  on  to  the  tube,  the  tube 
may  be  gradually  withdrawn  as  the  bowel,  now  collapsed,  is  re- 
placed gently  within  the  abdomen,  or,  if  thought  desirable,  the 
bowel  may  be  washed  out  with  warm  sterile  salt  solution.  This  is 
done  by  puncturing  the  bowel  at  the  highest  point  reached  with 
a  medium-sized  needle  to  which  a  long  India-rubber  tube  and  a 
funnel  are  affixed.  As  the  salt  solution  runs  into  the  bowel  it 
gradually  trickles  downwards  and  escapes  by  the  rubber  tube. 
The  glass  tube  is  withdrawn  slowly,  and  the  fluid  is  "milked" 
downwards  towards  its  outlet.  If  the  fluid  is  found  to  be  run- 
ning upwards  in  the  intestine  instead  of  downwards,  the  part  of 


ENTEROTOMY   AND    ENTEROSTOMY. 


409 


the  gut  immediately  above  the  point  of  entrance  of  the  needle  is 
lightly  closed  with  a  Doyen's  clamp  When  the  glass  tube  is 
almost  withdrawn,  the  flow  of  saline  solution  is  stopped.  If  nec- 
essary, one  or  two  ounces  of  Epsom  salts  dissolved  in  water  may 
be  introduced  through  the  needle  and  allowed  to  remain.  The 
needle  is  now  withdrawn,  and  the  point  of  puncture  closed  by  a 
few  Lembert  sutures  which  fold  the  intestinal  wall  transversely. 
The  bowel  is  now  replaced,  with  the  exception  of  the  loop  in  which 
the  incision  for  the  tube  was  made.     This  is  carefully  washed 


Fig.  184. — To  shew  the  position  of  the  tube  when  as  much  of  the  tube  as  possible 

has  been  drained  by  it. 

after  the  removal  of  the  tube,  and  closed  by  a  double  line  of  sut- 
ures— one  including  all  the  coats,  the  outer  picking  up  the  serous 
and  muscular  coats  only.  Great  care  is  expended  upon  these 
sutures,  since  they  are  being  introduced  into  a  gut  already  dam- 
aged by  overdistension  and  perhaps  by  ulceration.  A  final 
cleansing  of  the  loop  is  now  made,  and  the  whole  bowel  is  replaced 
and  the  wound  closed.  If  the  bowel  has  suffered  excessive  dam- 
age from  overlong  distension,  a  point  higher  than  ten  inches  from 
the  constriction  may  be  selected.  On  this,  the  operator  must  de- 
cide. It  is  essential  to  select  a  spot  whose  appearance  and  con- 
sistence are  as  little  different  from  the  normal  as  possible. 


410  ABDOMINAL   OPERATIONS. 

ENTEROSTOMY. 

The  operation  of  enterostomy  consists  in  the  fixing  of  the 
bowel  to  the  abdominal  wall  and  the  opening  of  the  bowel  for 
the  purpose  of  allowing  an  escape  of  its  contents.  Two  forms 
of  opening  are  made.  In  the  one,  the  small  intestine  or  the 
caecum,  as  a  rule,  is  opened  for  the  purpose  of  temporary  drainage, 
a  fcBcal  fistula  being  made.  In  the  other,  the  large  intestine,  as  a 
rule,  is  opened  for  the  purpose  of  permanent  drainage,  an  arti- 
ficial anus  being  made. 

Temporary  drainage  of  the  intestine  is  generally  adopted 
when,  in  cases  of  acute  intestinal  obstruction,  the  patient  is 
in  such  peril  that  only  the  smallest  possible  interference  can  be 
tolerated.  In  circumstances  such  as  these  any  search,  how- 
ever brief,  however  skilfulty  performed,  would  add  a  con- 
siderable danger  to  the  operation.  The  purpose  of  the  surgeon 
is  then  to  give  relief  to  the  obstruction  in  the  simplest  manner, 
as  speedily  as  possible,  with  the  least  possible  disturbance  of 
parts,  leaving  everything  but  the  overloading  of  the  intestine 
to  be  accomplished  later.  In  some  cases  of  obstruction,  as 
Nelaton  long  ago  pointed  out,  a  mere  rehef  from  overdisten- 
sion will  permit  a  return  to  the  normal.  But  such  a  fortunate 
event  is  of  the  greatest  rarity,  and  it  should,  therefore,  not  be 
urged  as  a  measure  of  persuasion  to  do  an  imperfect  operation 
except  in  times  of  the  greatest  stress. 

Enterostomy  may  also  be  performed  at  times  with  con- 
spicuous success  in  cases  of  post-operative  paralytic  distension 
of  the  intestines  where  the  patient  is  hastening  to  his  end. 

The  operation  of  enterostomy,  the  formation  of  a  fascal 
fistula  in  the  small  intestine,  is  performed  as  follows:  The 
skin  being  anaesthetised  (a  general  anaesthetic  is  not  necessary), 
the  abdomen  is  opened  by  an  incision  about  2^  inches  in  length 
in  the  right  iliac  region.  This  position  of  the  incision  is  that 
originally  advocated  in  1840  by  Nelaton,  and  it  possesses  many 
advantages.     The  first  and  chief  est  is  that  if  the  caecum  be  dis- 


ENTEROTOMY  AND  ENTEROSTOMY. 


411 


tended,  it  can  be  opened, — typhlotomy, — but  if  it  be  collapsed, 
a  point  in  the  ileum  low  down  is  likely,  as  shewn  by  Monks 
and  others,  to  present  itself  in  the  wound.  The  advantage 
of  having  the  opening  in  the  bowel  as  low  down  as  possible 
needs  no  emphasis.  As  soon  as  the  abdomen  is  opened  the 
caecum  or  a  distended  coil  of  the  bowel  is  seized  and  drawn  gently 
outwards.  The  position  and  direction  of  the  loop  of  gut  se- 
lected should  be  changed  as  little  as  possible.     The  bowel  is  now 


Fig-   185. — Enterostomy.     Faecal  fistula — for  drainage  of  intestine.     The  purse- 
string  suture  is  tightened  around  a  tube. 


fixed  to  the  parietal  wound.  Two  sutures,  one  at  each  end, 
are  first  introduced.  They  pass  through  all  the  layers  of  the 
abdominal  wound  on  one  side,  then  pick  up  a  broad  piece  of 
the  serous  and  muscular  coats  of  the  intestine,  and  then  pierce 
the  opposite  edge  of  the  wound,  passing  through  all  the  layers. 
These  two  sutures,  one  at  each  extremity  of  the  portion  of  bowel 
to  be  fixed  into  the  wound,  secure  a  good  attachment.  They 
are  left  loose  until  a  later  stage.  The  peritoneal  edges  are  now 
seized  with  two  pairs  of  clips  on  each  side,  and  a  continuous 


412 


ABDOMINAL   OPEEATIONS. 


suture  of  fine  Pagensteclier  thread  is  introduced  to  unite  the 
serous  covering  of  the  bowel  to  the  parietal  peritoneum  and  the 
muscle  (or  aponeurosis  in  the  middle  Hne)  superficial  to  it .  If  the 
needle  pass  only  through  the  peritoneum,  it  may  tear,  and 
a  firmer  hold  is  therefore  desirable.  It  is  most  important, 
though  sometimes  difficult,  to  avoid  a  penetration  of  all 
the  coats  of  the  bowel  when  passing  tliis  suture.  The  skin 
should  never  be  included.  When  this  suture  is  completed, 
the    through-and-through    sutures   are   tied.     The   gut   is    now 

ready  to  be  opened, 
but  it  is  desirable  to 
postpone  the  opening, 
if  it  can  be  done  with 
safet}',  for  a  few  hours. 
A  delay  of  even  a  couple 
of  hours  will  ens-ure  a 
fairly  accurate  sealing- 
off  from  the  peritoneal 
cavit}^.  From  the  in- 
flamed peritoneum, 
lymph  is  rapidly  poured 
out.  When  the  bowel 
is  opened,  it  is  desirable 
to  have  some  appa- 
ratus at  hand  where- 
with to  carry  oif  the 
profuse  discharge.  A  Paul's  tube  to  the  outer  end  of  which 
a  large  drainage-tube  is  attached  is  the  most  efficient  of  all. 
One  of  medium  size  will  be  found  adequate.  A  somewhat 
similar  tube,  used  in  America,  is  known  as  "]\Iixter's"  tube. 
Before  opening  the  bowel  a  purse-string  suture  is  apphed  around 
the  spot  at  which  the  opening  is  to  be  made.  When  the  tube 
is  introduced,  this  suture  is  tied  aroimd  the  tube,  and  for  the  time 
prevents  leakage.  After  two  to  five  days,  the  suture  works 
loose  and  the  tube  wih  be  found  to  sHp  out.     A  second  suture 


Fisr.  iS6. 


-Typhlotomy.     The    chief    sutures 
in  position. 


ENTEROTOMY  AND  ENTEROSTOMY.  413 

can  then  be  applied,  which  will  act  for  a  couple  of  days  longer, 
and  will  thereby  postpone  the  soiling  and  irritation  of  the  sur- 
rounding skin.  Around  the  tube  sterile  gauze  is  packed  so  as 
to  keep  it  fairly  steady,  and  this  is  changed  from  time  to  time 
as  seems  necessary.  When  the  tube  has  finally  worked  loose 
and  has  been  removed,  the  intestinal  contents  are  discharged 
on  to  the  surface.  As  a  rule,  it  is  not  long  before  the  skin  shews 
signs  of  redness  and  excoriation,  and  finally  an  intensely  red, 
angry-looking,  eczematous  condition  results.  If  the  opening 
be  anywhere  in  the  small  intestine,  the  condition  of  the  pa- 
tient is  lamentable  and  an  early  closure  of  the  fistula  is  desirable. 
As  each  peristaltic  wave  reaches  the  opening  there  is  a  spurt 
of  faecal  material  or  of  intestinal  juice,  and  the  patient  ex- 
periences a  fresh  accession  of  burning,  almost  intolerable  pain. 
His  condition,  to  say  the  truth,  is  one  of  abject  misery.  The 
only  relief  to  be  obtained  in  such  circumstances  is  afforded  by 
keeping  the  patient  once  or  twice  a  day  in  a  warm  bath  for 
an  hour.  The  skin  irritation  can  be  to  some  extent  prevented 
by  a  frequent  cleansing  and  by  painting  over  the  skin  a  sat- 
urated solution  of  pure  rubber  in  benzine.  This  should  be 
applied  from  the  first,  and  a  protective  coating  thereby  given 
to  the  abdominal  wall.  Despite  all  care,  however,  the  sore- 
ness of  the  skin  will  almost  inevitably  occur. 

It  is,  as  I  have  said,  important  that  the  continuous  suture 
fbdng  the  gut  should  not  include  the  skin.  The  fistula  is  the 
more  likely  to  close  spontaneously  if  the  skin  is  not  included. 
The  gut  is,  in  fact,  stitched  to  the  abdominal  w^all  in  much 
the  same  manner  as  the  gall-bladder  occasionally  is  in  the  opera- 
tion of  cholecystotomy,  and  in  these  cases,  as  in  those,  the  fistula 
will  shew  a  tendency  to  close.  Closure  of  the  gall-bladder  is, 
however,  a  matter  of  certainty;  closure  of  a  fsecal  fistula,  per- 
formed in  the  manner  described,  is  possible,  though  not  frequent. 
In  many  instances  the  fistula  has  to  be  closed  by  operation  in  a 
manner  to  be  presently  described. 

It  is  a  matter  of  great  importance  that  the  opening  should 


414  ABDOMINAL   OPERATIONS. 

be  made  into  the  intestine  as  low  down  as  possible.  The  reasons 
for  this  are  many.  The  high  opening  of  the  gut  involves  the 
risk  of  starvation.  In  those  instances  where  the  jejunum  has 
been  opened  a  speedy  loss  of  weight  follows,  as  might  be  an- 
ticipated. It  is  possible,  in  some  such  cases,  to  feed  the  pa- 
tient by  the  fistula  and  so  keep  him  alive  or  improve  his  con- 
dition, but  an  early  closure  of  the  fistula  is,  as  a  rule,  imperative. 
If  the  opening  is  made  even  three  or  four  feet  away  from  the 
caecum,  the  bowel  below  the  opening  shews,  as  was  pointed 
out  by  Lennander,  the  most  remarkable  tendency  to  contract 
adhesions.  At  a  secondary  operation  for  the  closure  of  the 
fistula  the  separation  of  these  intricate  adhesions  may  be  ex- 
tremely difficult,  and  when  the  channel  has  been  made  com- 
plete, an  intestinal  obstruction  may  be  caused  by  them.  In 
one  such  case  of  my  own  a  third  operation  had  to  be  performed, 
and  the  gut  at  the  site  of  the  faecal  fistula  joined,  by  lateral  an- 
astomosis, to  the  transverse  colon.  For  these  reasons,  then, — 
the  impossibility  of  recognising  with  the  limited  incision  and 
with  the  necessary  absence  of  handling  the  exact  portion  of  the 
intestine  which  is  seized,  and  the  tendency  to  the  formation 
of  intricate  and  inseparable  adhesions  in  the  collapsed  intestine 
below  the  fistula, — it  is  desirable  to  select  for  the  opening, 
whenever  possible,  the  caecum  rather  than  the  small  intestine. 
It  is  said  that  subsequent  closure  of  a  cascal  fistula  is  more  dif- 
ficult than  in  the  case  of  an  intestinal  fistula.  This  has  cer- 
tainly not  been  my  own  experience;  for  in  those  cases  of 
growth  in  the  large  intestine  in  which  obstruction  has  been 
acute,  the  faecal  fistula  has  acted  well,  and  when  a  later  re- 
section and  end-to-end  union  of  the  colon  have  rendered  the 
channel  once  more  pervious,  the  fistula  has  often  closed  spon- 
taneously or  become  materially  reduced  in  size,  so  that  an 
operation  for  its  closure  was  of  the  simplest  character.  If 
the  caecum  is  found  collapsed,  the  intestine  must,  of  course, 
be  opened,  but,  speaking  generally,  the  opening  of  the  caecum 
is  to  be  preferred  to  enterostomy. 


ENTEROTOMY  AND  ENTEROSTOMY. 


415 


In  some  cases  the  appendix  may  be  brought  up  to  the  sur- 
face, fixed  to  the  parietal  peritoneum,  and  opened  by  cutting 
away  the  last  half  inch.  A  catheter  may  then  be  passed  along 
the  lumen  of  the  appendix,  and  the  caecum  can  thereby  be  drained. 
When  it  is  desired  to  close  the  opening,  the  wound  can  be  re- 
opened and  the  appendix  be  removed.     This  operation,  first  sug- 


Fig.  1S7. — Appendicostomy.  The  incision  in  the  skin  is  made  long  to  shew 
the  details  of  the  operation.  It  need  not  be  longer  than  i  to  li  inches  when  the 
operation  is  performed  during  life. 


gested  by  Weir,   of  New  York,   is  known  as  Appendicostomy 
("Medical  Record,"  August  9,  1902). 

The  operation  of  enterostomy,  then,  in  certain  cases,  is  un- 
doubtedly a  life-saving  measure.  In  cases  of  advanced  intestinal 
obstruction,  when  the  bowel  is  overdistended  and  the  patient's 
condition  is  bad,  and  in  cases  of  so-called  paralytic  distension  as- 


4l6  ABDOMIX-\L   OPER-\TIOXS. 

sociated  with  septic  peritonitis,  due  more  often  to  appendicitis, 
a  patient's  life  may  undoubtedly  be  saved.  But  it  is  only  for 
such,  exceptional  cases  that  the  operation  should  be  reserved. 
It  is  true,  as  Nelaton  claimed,  that  in  a  certain  proportion  of 
cases  relief  to  the  overdistension  of  the  gut  permits  a  readjust- 
ment of  an  entangled  and  obstructed  gut,  so  that  the  normal 
condition  is  regained.  Such  an  occurrence  is,  however,  of  the 
rarest  and  should  never  be  expected.  It  is  far  more  likely  that 
even  after  relief  to  the  overdistension  the  mechanical  conditions 
of  obstruction  will  persist  and  will  lead  to  serious  disaster.  An 
ensnared  loop  will,  for  example,  go  on  to  gangrene,  or  perforation 
and  extravasation  will  occur.  Though  recovery  is  possible,  dis- 
aster is  not  improbably  impending.  The  opening  of  the  gut 
must,  therefore,  be  considered  only  as  a  temporary'  expedient — 
to  be  avoided,  if  possible;  to  be  resorted  to  only  under  the 
pressure  of  urgent  necessity. 


CHAPTER  XXIII. 

COLOTOMY. 

The  discussions  as  to  the  advantages  of  inguinal  over  lumbar 
colotom}^  or  vice  versa,  lose  much  of  their  interest  and  impor- 
tance if  two  points  be  conceded  by  the  adA^ocates  of  both  opera- 
tions.    These  two  points  are: 

1.  That  in  all  cases,  wherever  the  incision  may  lie,  the  peri- 
toneal cavity  should  be  opened. 

2.  That  in  cases  of  acute  obstruction  demanding  colotomy 
the  old  methods  should  be  abandoned,  and  a  Paul's  tube  be  at 
once  introduced  into  the  bowel  above  the  block. 

The  necessity  for  the  observance  of  the  first  point  will  be 
generally  admitted.  With  modern  methods  the  opening  of  the 
peritoneal  cavity  for  such  a  brief  period  as  is  needed  for  the 
performance  of  an  inguinal  colotomy  is  quite  devoid  of  risk. 
The  chief  point  in  the  former  advocacy  of  lumbar  colotomy 
depended  upon  the  fact  that  the  operation  could  be  performed 
without  opening  the  peritoneum,  and,  in  days  gone  by,  this 
statement  carried  great  weight.  The  extraperitoneal  opera- 
tion, however,  is  most  unsatisfactory,  for  when  the  colon  is 
brought  to  the  surface  and  opened  on  that  side  which  is  bare 
of  peritoneum,  a  comparatively  small  opening  is  made,  the  open- 
ing shews  a  constant  tendency  to  become  narrowed,  and,  as 
there  is  no  "spur"  at  the  opening,  there  is  an  unhindered  passage 
of  faeces  down  towards  the  rectum.  The  lodgment  of  faeces, 
constantly  increased  in  quantity,  in  the  parts  near  the  growth, 
teases  the  patient  in  many  cases  far  more  than  all  his  other 
discomforts.  Moreover,  the  necessity  for  an  extraperitoneal 
opening  being  made  belonged  to  an  age  of  ruder  surgery. 

So  far  as  the  second  point  is  concerned,  it  is  only  necessary 
to  say  that  it  is  by  the  use  of  a  Paul's  tube,  and  by  that  only, 
VOL.  I — 27  417 


41 8  ABDOMINAL   OPERATIONS. 

that  it  is  possible  for  the  bowel  brought  to  the  surface  to  be 
opened  at  once  without  risk  of  soiling  the  peritoneum.  The 
old  extraperitoneal  lumbar  colotomy  derived  its  chief  claim 
to  consideration  from  the  fact  that  the  bowel  could  be  opened 
instantly  without  any  chance  of  peritonitis  ensuing.  In  any 
form  of  colotomy,  however,  the  peritoneum  may  now  be  freely 
opened  and  its  soiling  be  secureh^  prevented  by  the  use  of  a 
Paul's  tube.  This  subject  is  considered  further  in  the  articles 
dealing  with  enterostomy  and  with  the  treatment  of  intestinal 
obstruction  due  to  growth  in  the  large  intestine. 

For  all  these  reasons  the  conclusion  is  reached  that  an 
intraperitoneal  operation  is  alwa^^s  desirable.  The  only  ques- 
tion, therefore,  to  be  decided  is  as  to  whether  an  opening  in 
the  loin  is  a  matter  of  greater  convenience  to  the  patient  than 
one  in  the  inguinal  region.  For  many  reasons,  which  will  be 
readily  understood,  an  opening  at  the  side  is  less  revolting 
than  one  on  the  anterior  surface  of  the  abdomen — it  is  out 
of  the  way,  so  to  speak.  But  being  so,  it  is  more  difficult  to 
attend  to  if  the  patient  has  to  rely  upon  himself  for  his  toilet. 
An  opening  in  front  is  readil}"  cleansed  and  the  dressings  are 
easily  changed. 

From  the  anterior  opening  there  is,  as  a  rule,  a  greater  ten- 
dency to  prolapse  of  the  bowel  than  from  a  lateral  opening. 
But  when  the  method  to  be  presently  described  is  adopted,  the 
likelihood  of  prolapse  to  an  extent  causing  discomfort  is  negli- 
gible. 

Much  has  been  written  about  the  distress  and  misery  caused 
to  a  patient  by  the  existence  of  a  colotomy  opening.  I  be- 
lieve that  this  is  largely,  if  not  solely,  due  to  improper  methods 
in  the  performance  of  the  operation;  to  the  extraperitoneal 
operation,  with  its  absence  of  spur  and  consequent  dribbling 
of  faeces  into  the  rectum ;  and  to  the  prolapse  from  an  inguinal 
opening.  I  do  not  find  that,  with  the  method  to  be  described, 
there  is  any  discomfort  or  distress  whatever  after  the  first  two 
months — after  the  time,  that  is,  that  the  patient  has  acquired 


COLOTOMY.  419 

some  control  over  the  opening.  I  have  recently  written  to 
eleven  patients  upon  whom  I  performed  colotomy  followed  by 
proctectomy  at  various  times,  all  over  six  months  ago.  Ten 
of  the  patients  expressed  themselves  as  perfectly  content,  and 
all  told  me  that  they  would  decline  any  further  operation  to 
close  the  colotomy  opening.  The  trouble  caused  by  the  opening 
was  so  slight  that  it  was  not  worth  while  entertaining  the  idea 
of  having  even  a  trifling  operation  performed  for  the  divert- 
ing of  the  faeces.  One  patient,  though  suffering  no  distress, 
said  she  would  prefer  to  have  an  operation  for  the  closure  of 
the  artificial  anus. 

In  the  following  description  of  the  operation  of  inguinal 
colotomy  the  steps  which  are  followed  after  the  abdomen  has 
been  opened  belong  equally  to  the  lumbar  operation,  and,  in- 
deed, to  colotomy  wherever  practised. 


INGUINAL  COLOTOMY. 

When  inguinal  colotomy  is  performed  the  sigmoid  flexure 
may  be  opened  as  high  as  possible  or  as  low  as  possible.  When 
opened  as  high  as  possible  there  is  no  fear  of  any  prolapse,  but 
there  is  little  or  no  fascal  continence.  When  opened  as  low  as 
possible,  there  is  a  liability  to  prolapse,  but  the  normal  reservoir 
for  the  faeces,  the  sigmoid  flexure,  is  preserved,  and  incontinence 
is  not  apt  to  occur.  The  ideal  operation  would  be  a  low  sigmoid 
colotomy  performed  in  such  a  manner  as  to  permit  the  patient  to 
have  good  control  over  the  faecal  evacuation.  I  have  recently 
practised  an  operation  which  seems  to  achieve  this  ideal: 

High  Sigmoid  Colotomy. — In  performing  the  operation  for 
inguinal  colotomy  it  is  perhaps  in  the  majority  of  cases  desirable 
to  open  the  sigmoid  flexure  as  high  as  possible.  In  this  manner 
the  undoubted  tendency  to  prolapse  is  lessened  or  even  abolished ; 
for  the  sigmoid  is  brought  to  the  surface  at  a  part  where  its 
mesentery  is  short,  and  the  support  of  that  segment  of  the  bowel 
engaged  in  the  operation  is  therefore  firm. 


420 


ABDOMINAL   OPERATIONS. 


The  abdominal  incision  is  made  on  the  left  side,  in  a  manner 
precisely  similar  to  that  which  is  adopted  upon  the  right  side 
in  the  removal  of  the  appendix ;  that  is  to  say,  that  the  muscles 
are  spHt,  as  suggested  by  McBurney,  and  their  fibres  are  not 
divided. 

The  incision  is  made  with  its  centre  at  a  line  which  joins 
the  umbilicus  to  the  anterior  superior  spine  of  the  ilium,  at  a 
distance  of  if  to  2  inches  from  the  anterior  superior  spine. 
If  the  abdominal  wall  is  very  lax  and  pendulous,  the  incision 
may  be  made  an  inch  higher  even  than  this.  The  skin  is  divided 
for  a  lensfth   not   exceeding  two  inches.     When  the   fibres   of 


Fig.  188. — Colotomy — the  muscles  are  split  in  the  manner  shewn:  a,  Fibres 
of  external  oblique;  h,  external  obliqvie  split;  a  small  nick  in  the  internal 
oblique,  at  the  outer  border  of  the  rectus;  c,  the  internal  oblique  and  trans- 
versalis  split. 

the  external  oblique  muscle  are  exposed,  it  will  be  found 
that  the  incision  lies  parallel  to  them.  These  fibres  are 
split  in  the  direction  of  their  length,  and  are  separated 
gently  from  one  another.  The  muscular  bundles  of  the  in- 
ternal oblique  are  then  exposed;  their  direction  is  almost 
at  right  angles  to  that  of  the  fibres  of  the  external  oblique.  A 
separation  of  these  muscular  bundles  is  effected  similarly  in  the 
direction  of  their  length.  This,  which  is  not  always  an  easy 
matter,  is  best  effected  by  beginning  the  separation  of  them 
as  near  as  possible  to  the  outer  border  of  the  rectus.  A  small 
incision  here  will  divide  or  separate  the  fibres  of  the  internal 


COLOTOMY.  421 

oblique  and  of  the  transA^ersalis  which  lie  beneath  it,  the  trans- 
versalis  fascia  and  the  peritoneum  being  exposed.  This  small 
incision  is  lengthened  by  gently  tearing  the  muscular  fibres 
apart  for  a  distance  of  about  i^  inches.  A  small  retractor 
is  then  placed  on  each  side  of  the  wound,  holding  the  muscles 
apart,  and  exposing  the  peritoneum,  in  which  an  incision  of 
an  inch,  or  rather  less,  is  made.  The  cut  edges  of  the  perito- 
neum are  seized  with  a  cHp  on  each  side. 

The  forefinger  is  then  introduced  into  the  abdomen  and 
the  sigmoid  flexure  is  sought.  As  a  rule,  there  is  no  difficulty 
whatever  in  finding  it  and  in  bringing  it  to  the  surface.  The 
simplest  method  of  seizing  it  at  once  is  to  sweep  the  finger 
along  the  peritoneum  on  the  outer  side  of  the  wound  across 
the  iliac  fossa  until  the  mesosigmoid  is  reached.  A  loop  of 
the  sigmoid  is  then  drawm  to  the  surface.  I  make  a  point  in 
all  cases  of  seeing  that  the  part  to  be  engaged  in  the  wound  is 
the  highest  part  of  the  sigmoid.  The  desirability  of  this  was 
first  shewn  by  Mr.  Harrison  Cripps.  As  soon  as  a  loop  of  the 
bowel  is  drawn  out  of  the  wound,  its  upper  end  is  drawn  upon 
until  no  more  of  the  bowel  will  come  out ;  at  the  same  time 
the  lower  portion  of  the  gut  is  returned  through  the  wound 
into  the  abdomen.  AVhen  the  highest  portion  of  the  sigmoid 
has  been  reached,  a  good  loop  of  the  bowel  is  drawn  out  of  the 
wound  and  its  mesentery  is  made  tense.  A  close  examination 
of  the  mesentery  is  made,  so  that  a  bloodless  spot  can  be  chosen 
for  the  passage  of  the  suture.  This  spot  should  be  about  i 
inch  from  the  gut.  The  suture  is  now  passed.  In  over  30 
consecutive  cases  I  have  used  only  one  suture  for  the  sup- 
port and  fixation  of  the  bowel.  This  stitch  was  first  sug- 
gested by  my  colleague,  ^Ir.  Edward  Ward.  In  introducing 
it  I  use  a  fully  curved  Hagedorn  needle  charged  with  thick 
Pagenstecher  thread.  The  needle  is  passed  from  the  centre 
of  the  incision  on  the  upper  or  inner  side  of  the  wound, 
being  introduced  about  ^  to  f  inch  from  the  cut  edge, 
through    the    skin,    external    and    internal    oblique    and   trans- 


422 


ABDOMINAL    OPERATIONS. 


versalis  muscles,  and  the  peritoneum.  The  dip  which  was 
put  on  to  the  edge  of  the  peritoneum,  immediately  after 
it  was  incised,  is  drawn  upon  gentty,  so  that  it  may  be  seen 

that  the  needle  takes  a  good 
hold  of  the  serous  surface.  The 
thread  is  pulled  after  the  needle 
until  onl}^  6  inches  remain  on 
the  outer  surface  of  the  skin. 
The  needle  now  passes  through 
the  mesentery  of  the  sigmoid 
at  the  bloodless  spot  alread}^ 
selected.  During  and  after  the 
time  that  tliis  is  done  the  loop 
of  the  sigmoid  with  its  mesen- 
tery is  held«  firmly  in  the  sur- 
geon's left  hand.  The  thread  is 
again  pulled  after  the  needle,  which  now  is  made  to  transfix 
the  outer  or  lower  margin  of  the  wound,  through  all  its  tliick- 
ness  from  peritoneum  to  skin.  The  thread  is  now  pulled  tight 
between  the  needle,  and  the  end  left  hanging  from  the  upper 


189. — Colotomy.  Shewing 
Ward's  stitch  in  horizontal  sec- 
tion. 


Fig.   190. — Colotomy.      Shewing  Ward's  stitch  in  transverse  section. 


side  of  the  wound.  The  needle  is  then  returned  through  the 
same  opening  in  the  mesentery  through  which  it  has  already 
passed,  the  needle  is  disengaged,  and  the  stitch  is  ready 
for  tying.     On  the  upper  side  of  the  wound  are  the  two  ends 


COLOTOMY. 


423 


of  the  thread — one  going  into  and  through  the  whole  thick 
ness  of  the  abdominal  wall,  the  other  emerging  from  the  open 
inginto  the  mesentery. 
On  the  lower  side  is  a 
loop.  When  the  su- 
ture is  tied,  a  piece  of 
medium-sized  drain- 
age-tube is  threaded 
through  this  loop,  so 
that  the  thread  may 
not  cut  into  the  skin. 
As  the  two  ends  of  the 
thread  are  knotted  to- 
gether, a  similar  piece 
of  tube  is  placed  in  the 
loop  so  formed.  The 
thread  is  drawn  upon 

firmly  and  deliberately  and  a  double  knot  is  tied 
the  thread  are  then  cut,  being  left  about  2  inches  long. 

This  stitch  affords  a  perfectly  firm  support  to  the  loop  of 

the  sigmoid.  It  secures  that 
a  good  loop  of  the  bowel  shall 
lie  external  to  the  skin,  and 
it  draws  the  skin-edges  into 
the  closest  approximation 
with  the  mesentery  on  each 
side.  There  is  no  risk,  there- 
fore, of  the  bowel  getting 
adrift  or  of  the  wound  being 
opened  more  widely  and  a 
large  amount  of  bowel  being 
extruded.  The  suture,  there- 
fore, possesses  every  advantage  over  the  glass  rod,  or  strip  of 
gauze,  passed  through  the  mesentery,  in  the  methods  adopted 
by  many  surgeons. 


Fig.  191. — Colotomy.     Operation  completed. 

The  ends  of 


Fig.  192. — Ward's  stitch,  in  "mattress 
form,  as  seen  in  horizontal  section. 


424 


ABDOMINAL   OPERATIONS. 


No  other  stitches  than  this  single  one  are  necessary.  If 
the  skin  incision  has  not  been  made  unduly  large,  it  will  be 
found  to  fit  the  loop  of  the  bowel  quite  snugly.  If  necessary, 
a  silkworm-gut* stitch  may  be  passed  at  each  end  of  the  wound; 
in  these  a  few  fibres  of  a  longitudinal  muscular  band  on  the 
bowel  may  be  included,  so  as  to  give  a  fixed  point  of  firm  union 
at  each  end.  This,  however,  is  not  necessary,  and  is  to  be 
performed  only  when  an  unduly  large  wound  through  the 
abdominal  wall  has  been  made. 

Any  loose  appendices  are  now  ligated  at  their  attachment 
with  fine  catgut,  and  cut  away. 


Fig.  193. — Ward's  stitch  in  "mattress"  form,  as  seen  in  transverse  section. 


A  square  of  boiled  dental  rubber,  or  of  oiled  silk,  is  now 
applied  over  and  around  the  loop  of  the  bowel,  and  an  ex- 
ternal dressing  of  wool  applied.  The  whole  operation  lasts 
from  ten  to  fifteen  minutes  and  may  be  done  under  local 
anaesthesia. 

The  supporting  stitch  may  also  be  passed  in  the  same  manner 
as  a  mattress  suture.  The  details  are  shewn  in  the  annexed 
drawings.  My  own  preference  is  for  the  first  form  of  the 
stitch. 

In  order  to  keep  the  bowel  from  action  and  to  quiet  the  pos- 
sible unrest  of  the  patient,  a  hypodermic  injection  of  I  or  ^  of  a 
grain  of  morphine  may  be  given,  and  repeated  at  the  end  of 
twenty-four  hours. 


COLOTOMY.  425 

The  time  at  which  it  is  necessary  to  open  the  sigmoid  flexure 
varies  much  in  different  cases.  If  there  be  an  acute  or  sub- 
acute obstruction,  it  may  be  imperative  to  open  the  gut  at  once ; 
in  such  circumstances  the  use  of  a  Paul's  tube  is  essential,  for 
it  is  only  in  this  way  that  the  wound  and  its  immediate  area 
can  be  kept  free  from  contact  with  f cecal  discharge.  If,  how- 
ever, there  be  no  undue  urgency,  at  least  three  days  may  be 
allowed  to  elapse  before  the  intestine  is  incised;  and  in  some 
instances  as  long  as  a  week  may  be  allowed  to  pass. 

I  have  in  many  cases  opened  the  bowel  at  the  end  of  two,  three, 
or  four  days,  and  have  allowed  the  supporting  stitch  to  remain 
in  for  several  days  longer.  It  is  true  that  until  this  stitch 
is  removed  the  bowel  does  not  empty  itself  quite  satisfactorily, 
but  there  is  free  escape  for  flatus,  and  for  fasces  in  sufficient 
amount  to  prevent  distress.  The  bowel  is  opened,  as  a  rule, 
by  an  incision  with  the  knife  of  a  Paquelin  cautery.  The  open- 
ing is  made  lengthwise  into  the  intestine,  and  at  first  should 
be  approximately  an  inch  in  length.  The  cautery  should  be 
of  a  dull  red  heat,  and  the  division  of  the  coat  of  the  gut  made 
slowly,  so  that  hemorrhage  is  prevented.  As  soon  as  the 
lumen  is  freely  exposed  it  will  be  seen  that  the  two  openings 
leading  from  the  surface  into  the  proximal  and  distal  limbs 
of  the  eventrated  loop  are  separated  by  a  well-marked  spur, 
the  end  of  which  lies  well  above  the  level  of  the  skin.  It  is,  there- 
fore, a  physical  impossibility  for  faeces  to  pass  onwards  into 
the  distal  opening:  they  must  first  escape  from  the  proximal 
opening  on  to  the  surface.  Through  the  distal  opening,  however, 
some  astringent  or  antiseptic  lotion  can  be  introduced  which 
will  pass  down  over  the  gro\\^h  and  out  of  the  anus,  through 
a  rectal  tube.  An  ulcerating  growth  in  the  bowel  can  there- 
by be  rendered  both  cleaner  and  sweeter,  and  that  condition 
of  irritating,  ichorous  discharge  which  is  sometimes  seen  can 
be  lessened  or  prevented. 

Low  Sigmoid  Colotomy. — I  have  recenth'  performed  an 
operation  having  for  its  objects  the  provision  of  a  controllable 


426 


ABDOMINAL   OPERATIONS. 


artificial  anus  and  the  preservation  of  the  normal  function  of  the 
sigmoid  flexure.  The  sole  disadvantage  of  the  method  just  de- 
scribed is  that  the  fsecal  material  as  soon  as  it  reaches  the  sigmoid 
flextire  is  free  to  escape  on  to  the  surface.  The  sigmoid  flexure 
should  act,  and  in  health  does  act,  as  a  f^cal  reservoir.     If,  there- 


Fig.  194. — Low  sigmoid  colotomy.  Shewing  the  bridge  of  skin  under  which 
the  upper  closed  end  of  the  sigmoid  flexure,  which  has  been  cut  through  as  low 
down  as  possible,  is  passed.  The  lower  incision  is  shewn  much  larger  than  is 
necessary. 


fore,  it  is  opened  as  low  down  as  possible  rather  than  as  high  up  as 
possible,  f^cal  material  coming  down  the  descending  colon  will 
not  instantly  be  discharged  upon  the  surface,  but  will  be  col- 
lected and  detained  to  a  convenient  time  in  a  capacious  loop  of 
bowel  destined  for  that  purpose.  As  a  rule,  when  the  sigmoid  has 
been  opened  low  down  there  has  been  a  prolapse  of  the  gut  through 


COLOTOMY. 


427 


the  opening.     This  can  be  prevented  by  the  method  now  to  be 
described. 

The  operation  is  performed  in  the  following  manner : 
The  abdomen  is  opened  by  the  muscle-splitting  incision  just 
described.     As  soon  as  the  sigmoid  is  exposed  it  is  drawn  11  p- 
wards  as  far  as  possible 
until    there    is   a   tight 
length  leadingto  the  rec- 
tum.    At  this  point  two 
clamps  are  placed,  and 
the  bowel  is  divided  be- 
tween them.    Both  ends 
of  the  gut  are  now  in- 
folded   and    closed    by 
suture.    (Thebow^elmay 
be     crushed,    ligatured 
and  closed  in,  if  desired.) 
The    distal  end   of  the 
bowel   is    fixed    to   the 
lower  angle  of  the  wound 
by  a  couple  of  stitches 
which  include  the  peri- 
toneum and  the  wall  of 
the  intestine.     The  up- 
per end  is  freed  a  little, 
so  as  to  render  it  more 
mobile  without   denud- 
ing it  of  its  blood-supply , 
and  is  brought  out  of 
the  wound  as  far  as  pos- 
sible.    A  few  stitches  fix  it  to  the  peritoneum,  and  the  muscles 
are  allowed  to  return  to  their  former  position.     The  upper  closed 
end  of  the  gut  is  now"  treated  in  one  of  two  ways :  either  it  is,  if 
freely  mobile  and  of  good  length,  passed  upwards  and  inwards 
under  a  bridge  of  skin,  made  by  undermining  the  skin  on  the  inner 


Fig.  195. — Low  sigmoid  colotom}'.  Sec- 
tion shewing  the  lower  end  closed  and  re- 
turned within  the  abdomen,  and  the  upper 
end  brought  to  the  skin.  A  pad  pressing  in 
the  direction  of  the  arrow  prevents  leakage. 


428  ABDOMINAL   OPERATIONS. 

side  of  the  T\-oiind  for  an  inch  and  a  half ;  a  second  smaller  incision 
is  then  made  through  which  the  end  of  the  bowel  is  pulled,  and 
the  original  wound  is  closed.  Or,  if  the  bowel  be  but  little  mobile, 
being  held  by  a  tight  mesenter3^  it  is  brought  at  once  to  the  skin 
surface  of  the  original  woiuid,  being  twisted  on  its  axis  for  half 
a  circle. 

If  the  former  method  is  possible  it  is  the  more  desirable ;  for 
after  the  bowel  has  been  opened,  the  subcutaneous  part  of  it  may 
be  so  compressed  by  a  pad  fixed  upon  an  abdominal  belt  as  to  be 
perfectly  controlled, — controlled  so  efficient^,  indeed,  as  to  pre- 
vent even  the  passage  of  flatus,  to  allow  which  to  pass  the  pad 
must  be  lifted  awa}^  from  the  abdomen. 

The  opening  of  the  bowel  is  left  for  two,  three  or  four  days,  as 
seems  necessarv^. 

I  believe  it  is  to  Wyeth,  of  New  York,  that  we  are  indebted 
for  this  suggestion  as  to  the  continued  usefulness  of  the  sigmoid 
reser\'oir. 

THE  LUHBAR  OPERATION. 

Limibar  colotomy  is  performed  in  a  manner  precisely  similar 
to  that  which  is  adopted  in  the  inguinal  operation;  the  sole 
differences  are  in  the  position  chosen  for  the  skin  incision  and 
in  the  fact  that  the  descending  colon,  which  is  not  at  all  or 
scantily  provided  with  a  mesentery,  is  opened  instead  of  the 
sigmoid  flexure.  The  incision  which  is  most  convenient  is 
that  which  is  generally  known  as  Br^^ant's  incision. 

The  patient  lies  well  over  on  the  right  side,  and  in  the  hollow 
of  the  right  loin  a  firm,  rounded  sand-bag  is  placed. 

The  incision  is  oblique  and  falls  upon  the  skin  between  the 
last  rib  and  the  iliac  crest. 

The  line  of  the  colon  is  marked  on  the  surface  from  a  point 
half  an  inch  behind  the  middle  of  the  line  joining  the  anterior 
and  posterior  superior  spines  vertically  upwards.  The  centre 
of  the  incision  lies  upon  this  line. 

The  incision  divides  the   skin,   thick  subcutaneous  tissues, 


COLOTOMY.  429 

and  the  muscles  down  to  the  fascia  lumborum,  which  is  opened 
by  a  small  incision.  The  opening  is  widened  by  gentle  tear- 
ing. The  fat  around  the  kidney  is  now  exposed  and  is  gently 
displaced  or  torn  away  with  the  fingers.  In  front  the  perito- 
neum Avill  be  seen. 

The  peritoneum  is  then  deliberately  opened  on  the  outer 
side  of  the  colon.  When  this  has  been  done,  there  is  no  diffi- 
culty whatever  in  discovering  the  colon.  As  a  rule,  it  comes 
unbidden  to  the  surface  and  is  seized  at  once.  If  it  should 
not  do  so,  the  left  index-finger  is  passed  into  the  wound  towards 
the  spine,  and  is  made  to  sweep  along  the  front  of  the  kidney 
until  it  is  felt  to  meet  the  colon,  which  is  hooked  upwards 
and  drawn  out  of  the  wound.  By  pulling  gently  upon  the 
colon  the  peritoneum  on  each  side  of  it  is  also  drawn  upon,  in 
such  manner  as  to  fashion  a  sort  of  mesocolon.  It  is  through 
this  mesocolon  that  Ward's  stitch,  already  described  and 
illustrated,  is  passed.  Mr.  Ward  devised  this  most  satisfactory 
suture  expressly  for  the  operation  of  lumbar  colotomy,  and 
it  is  safe  to  say  that  no  method  for  the  performance  of  the 
operation  approaches  this  one,  so  far  as  the  perfect  character 
of  the  opening — and,  therefore,  so  far  as  the  comfort  of  the 
patient — is   concerned. 

In  some  patients  the  depth  of  the  w^ound  may  make  it  neces- 
sary or  desirable  to  introduce  a  small  drain  in  the  posterior 
half,  or  possibly  in  the  anterior  half  also,  in  order  to  prevent 
an  accumulation  of  serous  fluid  in  so  deep  a  pouch.  In  rarer 
instances  the  wound  from  the  skin  to  the  peritoneum  may 
be  of  so  great  a  depth  that  the  colon  cannot  be  made  to  reach 
the  surface.  In  such  circumstances  there  is  nothing  to  be  done 
but  to  close  the  wound  and  to  open  the  abdomen  in  the  manner 
already  described  by  an  incision  for  the  performance  of  inguinal 
colotomy.  Such  a  condition  of  things,  it  is  true,  is  rarely  met 
with,  but  I  was  unfortunate  enough  to  experience  it  in  one 
case. 

The   difficulty  due  to   an  extremely  short  mesentery  may 


430  ABDOMINAL   OPERATIONS. 

also  be  encountered  in  inguinal  colotomy.  If  so,  it  may  be 
overcome  in  one  of  two  ways :  either  the  parietal  peritoneum 
may  be  stripped  from  the  edges  of  the  abdominal  wound  and 
tucked  down  to  the  sigmoid  flexure  by  a  series  of  sutures,  the 
opening  of  the  bowel  being  delayed  for  several  days;  or  the 
bowel  may  be  cut  completely  across,  and  each  cut  end  gently 
stripped  up  until  it  can  be  made  to  reach  the  surface,  or,  better, 
to  project  well  beyond  it;  the  bowel  is  then  stitched  to  the 
skin.  A  part  of  the  ends  may  slough,  owing  to  defective  nutri- 
tion, but  enough  will  remain  to  ensiire  an  adequate  opening 
on  the  surface. 

LILIENTHAL'S  COLOTOMY. 

Colotomy  after  the  method  of  Lilienthal  is  performed  as  fol- 
lows: A  muscle-splitting  incision  3^-^  to  4  inches  long  is  made 
through  the  left  rectus,  the  upper  end  of  this  incision  reaching 
almost  to  the  line  of  the  umbilicus.  The  abdomen  being  opened 
and  explored,  a  loop  of  the  sigmoid  flexure  is  drawn  out.  The 
two  limbs  of  this  loop  are  sutured  as  widely  as  possible  apart, 
one  to  the  peritoneum  and  rectus  sheath,  at  the  upper  end  of  the 
incision,  the  other  similarly  at  the  lower. 

Silk  or  linen  thread  is  used  for  the  suture  material.  Lilien- 
thal stitches  with  a  continuous  suture,  tying  every  third  stitch 
so  as  to  avoid  closing  the  lumen  of  the  gut.  The  mesosigmoid 
is  sutured  by  a  through-and-through  stitch  to  the  peritoneum  on 
each  side.  The  gut  is  now  divided  at  the  lower  end  of  the  loop 
between  two  ligatures,  and  the  mucosa  sterilised  with  pure  car- 
bolic. 

Mattress  sutures  are  passed  through  the  mesosigmoid,  which 
is  then  divided  so  as  to  separate  a  longer  length  of  colon. 

At  this  stage  of  the  operation  the  condition  of  affairs  is  as 
follows:  There  is  a  short  piece  of  sigmoid — the  distal  loop — sut- 
ured to  the  lower  angle  of  the  wound,  and  a  long  piece  (3  or  4 
inches)  completely  freed  except  at  its  attachment  to  the  upper 
angle  of  the  wound.     Four  clips  are  now  placed  on  the  mouth  of 


COLOTOMY. 


431 


the  proximal  loop,  and  a  finger  inserted  into  the  lumen  up  to  the 
site  of  suture  to  the  peritoneum. 

The  clamps  are  then  rotated  by  the  assistant  around  the  longi- 
tudinal axis  of  the  gut  in  such  a  manner  as  to  produce  a  certain 
degree  of  constriction,  the  degree  of  rotation  necessary  varying 
from  180  to  300  according  to  the  thickness  of  the  sigmoid.     A  few 


Fig.  196. — Lilienthal's  colotomy. 

interrupted  Pagenstecher  sutures  are  now  passed  from  the  muscu- 
lar aponeurosis  of  the  external  oblique  to  the  gut,  taking  in  the 
submucosa.  As  many  of  these  stitches  as  are  necessary  to  hold 
the  sigmoid  in  the  twisted  position  are  inserted.  The  anterior 
sheath  of  the  rectus  is  now  closed,  a  rectal  tube  is  tied  6  inches 
into  the  gut,  and  the  remainder  of  the  wound  packed  with  gauze. 
The  tube  is  removed  in  about  seven  days,  and  the  redundant 


432 


ABDOMINAL   OPERATIONS. 


sigmoid  cauterised.     The  ligature  round  the  lower  piece  of  in- 
testine is  removed  in  three  or  four  da\'s. 

Lilienthal  ("Annals  of  Surger^^  "  1910,  vol.  Hi,  p.  384)  claims 
that  the  advantage  of  this  colotom}'  over  all  others  is  that  the 
patient  has  control  over  the  opening  and  that  consequenth'  no 
appliance  beyond  a  simple  bandage  need  be  worn.     This  control 


Fig.  197. — Lilienthal's  colotomy. 

is  dependent  chiefl}^  on  the  sphincteric  action  of  the  left  rectus. 
There  is  also  a  sphincter  at  the  site  of  the  rotation  and  an  angula- 
tion at  the  point  of  peritoneal  fixation. 

I  perform  the  Lilienthal  colotomy  in  a  fashion  exactly  simi- 
lar to  that  followed  in  the  inguinal  and  iliac  operations,  using 
Ward's  deep  stitch,  but  without  division  of  the  sigmoid  at  the 
primary  operation. 


CHAPTER  XXIV. 

ENTERO-ANASTOMOSIS,   LATERAL    ANASTOMOSIS,    OR 
SHORT-CIRCUITING. 

By  lateral  anastomosis,  or  short-circuiting,  of  the  intestine 
is  understood  the  creation  of  a  communication  from  the  bowel 
above  to  the  bowel  below  an  impenetrable  or  irremovable  stric- 
ture. A  lateral  anastomosis  may  be  used  either  as  a  final, 
perhaps  the  only  possible,  operation,  as  in  cases  of  growth  of 
the    intestine    causing    partial    occlusion,    when    secondary    de- 


Fig.  19S. — Entero-anastomosis  (isoperistaltic). 

posits  in  the  liver  or  elsewhere  are  already  present,  or  as  a 
temporary  measure,  to  give  present  relief  to  urgent  symptoms, 
and  thereby  to  prepare  the  way  to  a  later  resection  of  the  growth. 
If,  for  example,  there  be  a  large,  adherent,  irremovable  malig- 
nant  mass  in  or  near  the  csecum  which  is  causing  intestinal 

VOL.  I— 28  433 


434 


ABDOMINAL   OPER.\TIONS. 


occlusion,  the  ileum  above  the  growth  ma}^  be  united  to  the 
colon  at  any  point  well  beyond  the  growth — to  the  transverse 
colon  or  the  sigmoid  flexure,  for  example.  The  operation 
of  short-circuiting  is  one  of  frequent  use  and  of  great  service 
in  any  part  of  the  alimentary  canal.  Gastro-enterostomy 
for  pyloric  obstruction,  entero-anastomosis,  ileosigmoidostomy, 
are  all  operations  that  have  served  the  surgeon  well. 

It  is  impossible,  in  any  brief  statement,  to  disclose  the 
various  indications  for  the  performance  of  entero-anasto- 
mosis,  but  a  few  of    the    more   important    may    be    named. 

I.  In  intestinal  ob- 
struction due  to  growths 
in  the  large  or  small 
intestine,  where  primary 
resection  is  impossible 
or  inadvisable.  The 
performance  of  enter- 
ostomy, formerly  much 
practised,  is  consider- 
ably curtailed  if  this 
indication  be  observed. 
Lateral  anastomosis  in 
these  circumstances  is 
as  simple  and  as  safe  as 
enterostomy,  and  is  free 
.from  all  the  unpleasing 
attributes  of  a  faecal 
fistula. 

2.  In  cases  of  simple  stricture  of  the  intestine  due  to  cicatricial 
contraction  following  strangulated  hernia,  etc. 

3.  In  cases  of  tuberculous  disease  of  the  intestine  with  ex- 
tensive and  inseparable  adhesions,  with  the  matting  together 
of  many  feet  of  intestine  in  intricate  confusion. 

4.  In  some  cases  of  multiple  adhesions  due  to  recurrent 
appendicitis,  before  or  after  the  removal  of  the  appendix,  when 
symptoms  of  intestinal  difficulty  are  present. 

5.  As  a  part  in  the  operation  of  intestinal  exclusion. 

The  range  of  usefulness  of  this  operation  is  considerable 


Fig.  199. 


-Entero-anastomosis  (antiperi- 
staltic). 


ENTERO-ANASTOMOSIS   AND   LATERAL   ANASTOMOSIS.  435 

its  safety  remarkable,  and  its  performance  as  simple  as  that 
of  any  abdominal  operation.  In  comparison  with  end-to-end 
anastomosis  it  presents  the  undoubted  advantage  of  having 
the  line  of  anastomosis  completely  encircled  by  peritoneum. 
There  is  no  weak  spot,  as  there  is  at  the  gap  in  the  mesentery. 
Leakage,  therefore,  and  difficulty  of  suture  have  not  to  be 
reckoned  with;  the  only  point  requiring  care  and  judgment 
is  the  selection  of  the  most  fitting  place  for  the  anastomosis. 

In  cases  of  obstruction  due  to  growth  a  point  some  distance 
above  the  growth  should  be  selected,  for  that  condition  of  in- 
fection and  ulceration  of  the  mucosa  which  prevents  the  heal- 
ing of  a  wound  in  end-to-end  anastomosis  may  also  wreck 
a  lateral  approximation.  It  is  just  as  essential  in  this  opera- 
tion, as  in  resection,  to  suture  only  healthy  portions  of  the 
bow^el.  Lateral  approximation  should  not  be  made,  therefore, 
too  close  to  the  growth  on  either  side,  and  portions  of  the  bowel 
alone  should  be  selected  which  permit  of  ready  apposition  with- 
out drag  or  tension. 

So  far  as  the  means  of  effecting  the  junction  are  concerned, 
it  is  only  necessary  to  say  that  no  other  method  than  that  of 
simple  suture  should  ever  be  considered.  In  the  early  days 
of  my  experience  I  used  the  Murphy  button  to  effect  an  ileo- 
sigmoidostomy,  and  despite  the  fact  that  the  heavier  end  was 
placed  in  the  sigmoid,  the  button  made  its  way  into  the  cascum 
and  caused  ulceration  and  perforation.  Of  the  method  of 
simple  suture,  one  may  safely  claim  that  it  is  as  easy  as  any 
other  method;  that  with  practice  it  can  be  performed  with 
equal  rapidity;  that  disaster  to  the  suture-line  is  unknown; 
that  it  leaves  nothing  behind  which  can,  in  the  after-days,  be  a 
source  of  danger,  and  that  in  actual  practice  it  is  undoubtedly 
the  most  satisfactory.  In  short,  all  its  attributes  are  those 
of  excellence :  it  leaves  nothing  to  be  desired. 

The  following  is  the  method  I  adopt:  The  appropriate 
loops  of  bowel  having  been  chosen,  they  are  drawn  out  of  the 
abdomen  and  clamps  are  applied.     It  is  necessary  to  ensure 


436  ABDOMINAL   OPERATIONS. 

that  the  loops  to  be  united  are  appHed  to  each  other  so  that 
they  are  isoperistaltic.     In  the  small  intestine  this  is  perhaps 
of  little  importance,  but  when  the  small  and  the  large  intes- 
tine are  applied,   it  is  undoubtedly  an  advantage.     This  dis- 
position of  the  parts  is  ensured   by  seeing  that   the   proximal 
portion  of  the  gut  is  always  placed  near  the  pivot  end  of  the 
blade  of  the  forceps,  and  the  distal  portion  of  the  gut  towards 
the  tip  of  the  blade.     The  forceps  so  embracing  the  bowel  are 
now  made  to  lie  side  by  side,  and  hot  moist  mackintosh  cloths  sur- 
round them,  and  a  special  rolled  compress  lies  between  them. 
The  suture  is  then  applied.     The  needle  is  the  usual  curved 
needle,  and  the  thread  is  the  finest  Pagenstecher.     A  contin- 
uous seromuscular  suture  is  first  introduced,  along  a  line  about 
2  to  3  inches  in  length.     The  suture  is  knotted  after  the  first 
stitch  and  the  end  is  left  long;   it  is  then  continued  without  in- 
terruption or  knotting.     The  suture-line  lies  about  ^  inch  from 
that  portion  of  the  bowel  most  distant  from  the  mesentery,  on 
the  sides  of  the  bowel  which,  in  this  position  of  the  clamps,  are 
in   contact.      After  the   suture    reaches    the   portion   of  bowel 
at  the  tip  of  the  clamps'  blades,  the  needle  is  laid  aside.     The 
intestine  in  front  of  this  line  of  suture  is  now  opened  by  a  straight 
incision  about  2  inches  in  length,  which  divides  all  the  coats 
down  to  the  mucosa.     As  the  knife  cuts  through  these  coats 
they  retract,  until,  by  the  time  the  mucous  membrane  is  reached, 
an  ellipse  of  it  lies  in  between  the  wound-edges.     This  ellipse 
is  removed ;  a  snip  of  the  scissors  is  made  through  the  mucosa 
at  one  point,  and  the  scissors  are  then  carried  around  the  whole 
ellipse  until  it  is  free.     The  same  is  done  with  each  portion  of 
the  gut.     There  will  be  no  bleeding  from  the  cut  edges  of  the 
intestine,  for  the  clamp  which  holds  it  acts  as  a  temporary  hasmo- 
static.     The  lumen  of  each  portion  of  the  bowel  is  emptied  and 
thoroughly  cleansed  with  gauze  swabs,  which  are  thrown  away 
as  soon  as  they  are  soiled.     Care  must  be  taken  that  neither  the 
fingers  of  the  surgeon  nor  of  his  assistant  nor  any  of  the  parts 
around  are  soiled  with  the  intestinal  contents.     The  inner  su- 


ENTERO-ANASTOMOSIS   AND   LATER.\L   ANASTOMOSIS. 


437 


ture  is  now  introduced,  beginning  at  the  proximal  end  of  the 
incision.  A  similar  needle  and  the  same  size  of  thread  are  used. 
The  suture  embraces  all  the  coats  of  the  gut.  After  the  first 
stitch  the  thread  is  knotted,  the  end  left  long,  the  suture  then 
continued  along  the  posterior  margin  of  the  incisions  to  the  dis- 
tal end  of  the  wound,  and,  finally,  the  suture  is  continued  around 
the  anterior  margins  until  the  point  of  starting  is  reached,  when 


Fig.  200. — The  inner  suture  in  lateral  anastomosis  to  shew  the  infolding  of  the 
mucosa  which  results.     A  loop  of  the  suture  lies  on  the  mucous  surface. 

the  end  originally  left  long  is  tied  with  the  end  in  the  needle 
and  the  threads  cut  short.  This  inner  stitch  secures  a  perfect 
apposition,  which  is  water-tight,  and  it  is  drawn  sufficiently 
tight  to  secure  the  vessels  in  the  cut  edges.  As  each  stitch  is 
passed  the  thread  is  drawn  upon  with  sufficient  tension  to  lift 
up  those  portions  of  the  intestine  into  which  the  needle  has  next 
to  pass.     The  stitch  is  continuous  throughout ;  there  is  no  fear 


438  ABDOMINAL   OPERATIONS. 

of  its  causing  a  puckering  of  the  wound-edges.  With  this  su- 
ture special  care  must  be  taken  to  infold  the  mucosa.  This 
may  be  done  by  changing  the  suture  when  the  posterior  part 
of  the  intestine  has  been  sutured.  When  this  point  is  reached, 
the  needle  is  passed  from  the  mucosa  of  the  bowel  which  lies  to 
the  surgeon's  left  through  all  the  coats  to  the  serous  surface. 
Then  on  each  side  the  needle  picks  up  a  piece  of  the  edge  in  a 
suture  which  lies  parallel  to  the  cut  margin,  the  loop  of  the 
suture  being  always  on  the  mucous  surface  (Fig.  200).  After 
the  completion  of  this  suture  the  clamps  are  removed,  and  a 
general  cleansing  of  the  bowel  and  of  the  hands  is  made, 
for  the  mucosa,  which  is  probably  infected,  is  now  closed  off. 
It  is  often  desirable  for  the  surgeon  to  change  his  gloves. 
If  any  point  in  the  cut  edges  shews  any  sign  of  bleeding,  an 
interrupted  suture  is  introduced  and  tied  with  sufficient  force 
to  arrest  the  hsemorrhage.  The  first  needle,  which  carried  the 
seromuscular  stitch,  is  now  picked  up  and  the  suture  continued 
round  in  front  of  the  inner  stitch  and  about  ^  inch  from  it, 
until  the  point  from  which  it  started  is  reached.  The  end  of 
this  outer  suture,  if  dragged  upon  by  an  assistant,  will  facili- 
tate the  introduction  of  the  stitch  around  the  anterior  half 
of  the  wound.  The  two  ends  of  the  suture  are  now  tied  and 
cut  short  and  the  anastomosis  is  complete.  A  reference  to 
the  diagrams  used  in  the  description  of  the  operation  of  gas- 
tro-enterostomy  will  here  be  useful. 

A  junction  between  two  portions  of  the  bowel  effected  by 
this  suture  is  water-tight  at  once.  The  inner  suture  secures 
that.  It  is  remarkable  how  rapidly  the  outer  suture,  secur- 
ing accurate  peritoneal  approximation,  ensures  a  firm  union. 
In  one  case,  a  woman  of  sixty-seven,  I  performed  ileosigmoidos- 
tomy  for  acute  obstruction  depending  upon  a  growth  in  the 
caecum.  After  the  anastomosis  was  complete  an  assistant 
stretched  the  sphincter  and  I  milked  a  very  large  quantity  of 
thin  faecal  material  through  the  opening  into  the  sigmoid 
and  rectum.     The  patient  died  twenty-three  and  one -half  hours 


ENTERO-ANASTOMOSIS   AND   LATERAL   ANASTOMOSIS.  439 

after  the  operation,  and  the  suture  could  hardly  be  recognised, 
so  perfectly  was  it  sealed  off  by  accurate  peritoneal  adhesion. 
The  general  appearance  of  the  parts  was  such  that  it  was  diffi- 
cult to  believe  that  so  perfect  a  healing  had  been  possible  in 
so  short  a  time. 

The  same  technique  is  adopted  in  all  circumstances.  The 
only  difficulty  that  I  have  met  with  is  that  in  some  instances 
the  mesosigmoid  is  so  short  that  the  bowel  cannot  be 
drawn  outside  the  abdomen.  I  have  found  that  a  pair  of 
Doyen  curved  clamps,  applied  so  that  the  concavity  is  for- 
wards (towards  the  operator),  is  then  a  help.  If  these  can- 
not be  used,  then  the  sigmoid  must  be  temporarily  held  by  an 
assistant. 


CHAPTER  XXV. 
ENTERECTOMY. 

Enterectomy,  or  the  removal  of  a  portion  of  the  intestine, 
may  be  performed  upon  the  small  intestine,  in  any  part  of  the 
colon,  or  at  the  ileocascal  junction. 

Removal  of  a  portion  of  the  bowel  is  necessary  in  the  fol- 
lowing conditions: 

1.  In  new-growths. 

2.  In  stricture  of  the  intestine  due  to  former  or  present 
ulceration,  most  frequently  tuberculous  in  character,  or  follow- 
ing upon  strangulation. 

3.  Gangrene  of  the  intestine,  due  to  strangulation  in  a 
hernial  sac,  or  occurring  in  intestinal  obstruction. 

4.  Irreducible  intussusception,  associated  with  growth,  simple 
or  malignant. 

5.  In  some  forms  of  perforation  of  the  intestine  where  two 
or  more  wounds  lie  close  together,  as  in  gunshot  wounds. 

6.  In  extensive  lacerations  of  the  intestine  or  of  the  mesen- 
tery, of  the  kind  found  in  "buffer"  accidents,  or  as  the  result 
of  a  bayonet  or  stab -wound. 

7.  In  certain  cases  of  faecal  fistula,  designedly  or  accidentally 
produced. 

8.  In  cases  of  growth  in  the  mesentery  when  the  vascular 
supply  of  the  bowel  is  endangered. 

The  subject  will  be  considered  under  the  following  headings : 
Resection  of  the  small  intestine. 

(a)  For  grow^th  or  stricture,  or  in  cases  of  mesenteric 
tumour  when  the  vascular  supply  of  the  gut  is 
involved. 

(b)  In  cases  of  gangrene  dependent  upon  stran- 
gulated hernia  or  in  acute  obstruction. 

440 


ENTERECTOMY.  44 1 

Resection  of  the  large  intestine, 
(a)   For  growth. 
(6)    For  growth  causing  acute  obstruction. 

RESECTION  OF  THE  SMALL  INTESTINE. 

(a)  Resection  of  the  Small  Intestine  for  Growth  or  Stricture. — 

Growth  of  the  small  intestine  is  infrequent.  I  have  only  been 
called  upon  to  remove  malignant  growths  from  the  ileum  or  jeju- 
num on  seven  occasions.  Tuberculous  stricture  following  upon 
ulceration  is  occasionally  seen,  and  in  some  instances  the  thicken- 
ing in  the  gut  may  be  so  marked  as  to  cause  a  strong  resemblance 
to  primary  growth. 

The  abdomen  is  opened,  as  a  rule,  through  the  middle  line. 
If  the  tumour,  perceptible  before  the  operation,  seems  fixed 
in  any  part  of  the  abdomen,  the  incision  may  be  made  directly 
over  the  most  prominent  portion  of  it.  The  abdominal  in- 
cision is  made  in  the  usual  manner,  and  the  hand  is  introduced 
into  the  abdomen  and  a  general  examination  of  the  parts  is 
made.  If,  on  careful  exposure  of  the  growth,  it  is  found  that 
a  decided  obstruction  is  caused  by  it  and  that  the  gut  on  the 
proximal  side  is  acutely  distended,  no  resection  operation  can 
be  undertaken.  Enterectomy,  followed  by  primary  suture  in 
cases  of  intestinal  obstruction  due  to  growth,  is  doomed  to 
failure.  A  lateral  anastomosis  between  the  bowel  above  and 
the  bowel  below  the  growth  will  then  be  undertaken.  If,  how- 
ever, all  the  conditions  are  favourable  for  resection,  this  should 
be  done. 

The  bowel  is  first  carefully  isolated.  There  may  be  adhe- 
sions binding  the  growth  to  the  abdominal  wall,  to  a  neighbour- 
ing coil  of  intestine,  or,  as  is  most  commonly  the  case,  to  the 
omentum.  Many  of  these  adhesions  give  way  under  gentle 
pressure  or  with  gauze  stripping.  They  should  always  be 
detached  firmly  but  gently.  Roughness  and  impatience  are 
out  of  place.  Omental  adhesions  are  ligated  off  about  i-^  to 
2  inches  from  the  growth  if  possible.     If  any  part  of  the  intes- 


442  _  ABDOMINAL   OPERATIONS. 

tine  is  adherent  to  the  growth,  it  should  be  separated  ^ith 
especial  care.  In  three  cases  of  my  own  (two  of  gro-^i;h,  one 
of  tuberculous  disease)  a  separation  was  quite  impossible,  and 
the  adherent  loop  of  bowel  had  to  be  excised,  a  double 
enterectomy  being  performed.  On  a  subsequent  examination 
with  the  microscope  the  adherent  loop  was  found,  in  each  case, 
to  be  invaded  extensively  by  growth.  In  cases  of  tuberculous 
disease  the  adhesions  are  even  more  binding  and  more  com- 
plex than  in  cases  of  gro\\i:h. 

The  adhesions  having  been  separated,  the  involved  loop 
of  gut  is  drawn  well  out  of  the  abdomen,  so  that  the  full  ex- 
tent of  the  disease  and  of  the  glandular  enlargement  can  be 


*^ 


Fig.   20 1. — -Ligation  of  omentum.     The  interlocking  ligatures. 

seen.  The  limits  of  the  excision  having  been  determined  upon, 
as  many  large  swabs  as  are  necessary  are  placed  in  position,  so  as 
to  isolate  the  area  of  operation,  these  being  covered  in  turn  by 
mackintoshes. 

The  intestine  having  been  isolated  and  the  general  perito- 
neal cavity  shut  off  by  the  packing  of  swabs,  the  resection  is 
begun.  In  the  case  of  the  small  intestine  it  is  always  possible 
to  do  this  outside  the  abdomen,  and  there  is  every  advantage 
in  so  doing  it.  The  limits  of  the  gut  to  be  removed  being  de- 
termined, the  intestinal  clamps  are  applied.  Four  pairs  are 
necessary — two  pairs  at  each  point  of  section.  If  the  intestine 
is  at  all  distended  with  fa?culent  material  or  with  flatus,  the  lower 


ENTERECTOMY. 


443 


clamps  can  be  first  applied,  the  bowel  divided,  and  the  upper 
cut  end  drawn  away  from  the  wound,  its  clamp  removed,  and 
the  bowel  allowed  to  drain  away  its  contents  into  a  dish.  The 
upper  clamps  are  then  applied  and  the  intestine  between  them 
divided.     As  a  rule,  however,  no  emptying  of  the  intestine  is 


Fig.   202. — Enterectomy.      Removal  of  growth  of  intestine,  with  mesentery  and 
glands.     The  parts  are  ready  for  an  end-to-end  anastomosis. 


necessat^y,  and  the  clamps  both  above  and  below  may  be  applied 
at  once.  In  placing  them  in  position  it  is  important  to  remem- 
ber that  they  must  not  be  at  right  angles  to  the  longitudinal 
axis  of  the  intestine,  but  that  they  must  lie  obliquely,  so  that 
their  tips  approach  one  another.     A  triangular  portion  of  mesen- 


444 


ABDOMINAL   OPEIL\TIOXS. 


tery  with  its  portion  of  bowel  is  therefore  partly  included  in  the 
grasp  of  the  clamps,  the  apex  of  the  triangle  being  towards  the 
root  of  the  mesentery,  the  base  being,  of  course,  the  bowel  to 
be  removed.  By  so  applying  the  clamps  an  adequate  blood- 
supply  for  the  cut  ends  of  the  gut  is  assured,  and  a  slightty  larger 
section  of  the  intestine  is  left  for  the  anastomosis.  The  bowel 
is  now  divided  at  each  end,  and  the  cut  ends  at  once  cleansed 
with  many  swabs  wrung  out  of  saline  solution.  As  soon  as 
the  division  is  made,  each  end  of  the  intestine  is  temporarilv 
wrapped  in  a  swab  of  gauze  and  carefully  protected  so  that  no 


Fig.   203. — The  lines  of  section  of  small  intestine  and  mesenten"  in  a  case  of 
enterectomy  (Hartmann) . 

soiling  of  any  part  of  the  operation  area  by  contact  with  a  cer- 
tainly infected  mucosa  can  occur.  The  incision  is  carried  on- 
wards, obliquely  into  the  mesenter}^,  and  any  bleeding  points 
at  once  seized  with  clips.  Or,  as  is  my  usual  practice,  the  apex 
of  the  wedge  of  mesentery  to  be  removed  is  found  and  isolated 
and  a  broad  clip  of  my  own  pattern  is  applied  to  it.  The  clip 
is  squeezed  home  and  allowed  to  remain  for  a  few  seconds.  When 
it  is  removed,  a  deep  groove  will  be  seen,  all  except  the  vessels 
and  the  peritoneum  having  been  squeezed  away  by  the  pres- 
sure of  the  forceps.     Into  the  groove  so  left  a  catgut  ligature 


ENTERECTOMY.  445 

or  a  fine  Pagenstecher  ligature  is  placed  and  tied.  A  clamp  is 
then  applied  about  i  inch  distal  to  the  ligature,  and  the  mesen- 
tery between  them  is  divided.  The  remainder  of  the  mesentery- 
is  now  cut  through  on  each  side,  and  the  whole  affected  loop  is 
free.  Some  vessels  in  the  cut  mesentery  near  the  bowel  will 
require  clipping.  In  this  portion  which  is  now  removed  will 
be  the  growth,  a  length  of  healthy  bowel  on  each  side,  and  a 
wedge  of  mesentery  containing  all  the  lymphatic  vessels  and 
glands  draining  the  diseased  intestine.  The  condition  of  affairs 
at  this  stage  of  the  operation  is  represented  in  Fig.  i6o.  A 
general  cleaning-up  of  the  operation  area  is  now  necessary. 
The  mackintoshes  are  changed,  the  ends  of  the  bowel  are  cleansed 
again,  and  the  hands  are  well  rinsed  in  fresh  sterile  salt  solution. 
The  approximation  of  the  divided  ends  by  suture  is  now  begun. 
The  clamps  are  drawn  together  and  laid  side  by  side,  and  wrapped 
around  with  hot  moist  gauze.  If  the  upper  opening  of  the  bowel 
is  rather  larger  than  the  lower,  as  may  be  the  case,  a  longitudinal 
incision  is  made  into  the  lower  portion  along  a  line  most  distant 
from  the  mesenteric  attachment.  The  stitches  are  now  intro- 
duced. That  portion  of  the  bowel  at  the  mesenteric  edge  is  first 
stitched,  and  very  especial  care  is  taken  with  the  first  few  turns 
of  the  needle.  The  first  stitch  is  seromuscular,  and  picks  up  the 
outer  covering  of  the  bowel  about  %  inch  from  the  cut  edge. 
The  suture  begins  near  the  mesenteric  attachment,  and,  in  the 
first  two  passages  of  the  needle,  only  the  mesentery  is  pierced  on 
each  side.  As  the  mesentery  reaches  the  intestine  its  layers  sep- 
arate, leaving  a  triangular  gap.  It  is  the  mesentery  bounding 
the  triangular  gap  which  is  picked  up  by  the  first  turns  of  the 
needle.  The  suture  is  then  continued,  including  the  serous  and 
muscular  coats  only  (perhaps  the  submucous,  or  a  part  of  it, 
also),  until  one-half  the  circumference  of  the  bowel  is  united, 
until,  that  is  to  say,  the  part  of  the  gut  most  distant  from  the 
mesentery  is  reached.     The  needle  is  then  laid  aside. 

The  inner  suture  is  now  introduced.     This  includes  all  the 
coats  of  the  bowel,  and  ensures  two  results — a  perfect  mechani- 


446 


ABDOMINAL   OPERATIONS. 


cal  approximation  of  the  divided  ends  of  the  bowel  and  haemos- 
tasis.  It  is  not  necessary  to  clip  and  to  ligate  any  points  in 
the  cut  edge  of  either  end  of  the  intestine.  To  introduce  the 
stitch  skilfully  some  practice  is  required.  Owing  to  prolapse 
or  retraction  of  the  mucosa,  it  may  be  difficult  to  pick  up, 
on  the  needle-point,  precisely  that  amount  of  intestine  which  is 
necessary.  The  stitch  may  at  first  be  drawn  overtight;  it  is 
more  likely,  however,  that  it  will  not  be  drawn  tight  enough. 
I  have  found  the  best  standard  of  the  necessary  degree  of  tight- 
ness that  which  results  from  a  drag  upon  the 
thread  from  the  last  stitch  of  a  degree  suf- 
ficient to  raise  up,  prominently,  that  part 
of  the  walls  of  the  intestine  into  which  the 
needle  is  next  to  pass.  If  the  thread  be 
drawn  steadily  and  held  firmly  upwards,  it 
raises  the  portion  of  bowel  through  which 
the  needle  last  passed,  and  makes  prominent 
that  part  which  is  about  to  be  caught  up  in 
the  needle.  It  is  the  fiirst  two  turns  of  this 
suture  which  are  of  the  chief  est  importance. 
By  them  the  gap  at  the  junction  of  the  mes- 
entery and  of  the  bowel  is  closed,  and  a 
perfect  serous  apposition  ensured.  As  the 
two  openings  lie  side  by  side  there  are  two 
triangular  gaps,  in  the  right  and  left  di- 
vided ends  of  the  intestine.  The  stitch  is  begun  by  being 
passed  from  the  mucosa  of  the  lumen  of  the  bowel  on  the  right, 
through  all  the  wall  of  the  bowel,  and  through  that  portion  of 
the  mesentery  which  has  just  separated  from  its  fellow  at  the 
gap;  from  there  the  needle  passes  to  the  bowel  on  the  left, 
transfixing  all  the  coats,  beginning  with  the  separating  layer  of 
mesentery  and  passing  then  into  the  lumen  of  the  bowel ;  from 
here  it  pierces  the  mucosa  about  |  inch  from  the  point  of  its 
last  emergence  through  all  the  coats  and  through  the  other  leaf 
of  the  mesentery ;  and,  finally,  it  passes  from  the  mesentery  to 


Fig.  204. — End- 
to-end  anastomosis 
after  enterectomj^ 


ENTERECTOMY. 


447 


the  mucosa  of  the  portion  of  intestine  to  the  right,  entering  the 
lumen  of  this  bowel  through  the  mucosa  about  |-  inch  from  its 
original  point  of  entry ;  the  suture  is  tied  and  the  end  left  long. 
(A  reference  to  the  annexed  diagram  will  make  the  path  of  the 
needle  clear.)  The  suture  is  now  continued  around  the  posterior 
half  of  the  margins  of  the  opening,  embracing  all  the  coats  and 
being  pulled  fairly  tight  and  even.  No  puckering  of  the  gut 
need  be  feared.  Each  individual  portion 
of  the  stitch  must  be  separately  tightened. 
If  one  loop  be  left  slack,  it  cannot  be 
tightened  later  without  releasing  all  the 
stitch.  The  suture  approximates  first  the 
posterior  margins,  and  then,  without 
change  or  interruption,  is  passed  along 
the  anterior  margins  until  the  end,  left 
long  at  the  first  stitch,  is  reached,  when 
the  thread  is  knotted  and  cut  short.  As 
the  stitch  passes  along  the  anterior  margin 
it  is  important  to  see  that  the  mucosa  is 
infolded.  This  may  best  be  done  by  chang- 
ing the  type  of  stitch.  The  needle  is  passed 
twice  through  the  bowel  on  each  side: 
from  serosa  to  mucosa  and  back  again 
to  serosa  on  the  one  side,  then  similarly 
on  the  opposite  side,  so  that  a  loop  lies 
always  on  the  mucous  surface.  As  the 
suture  is  tightened  the  mucous  m.embrane 

is  infolded.  The  last  turn  of  this  stitch  passes  from  serosa  to 
mucosa  onty,  and  there  the  knot  is  tied.  The  clamps  are  now 
removed  from  the  intestine,  as  the  ends  are  securely  closed, 
in  order  to  see  if  the  suture -line  bleeds  at  all.  As  a  rule,  the 
haemostasis  is  perfect,  but  once  and  again  a  point  will  be  found 
to  bleed.  A  separate  interrupted  stitch  is  then  passed  to  in- 
clude this  point.  The  arrest  of  the  hasmorrhage  being  complete, 
the  bowel  is  again  gently  washed,  and  the  seromuscular  stitch. 


Fig.  205. — End-to- 
end  anastomosis  con- 
tinued. 


448 


ABDOMINAL   OPERATIONS. 


laid  aside  for  a  time,  is  now  restarted.  The  circuit  is  com- 
pleted by  carrying  this  suture  along  the  anterior  margins  until 
the    mesentery  is  reached.     Two  turns  of  the  needle  are  then 


Fig.  206. — The  first  portion  of  the 
inner  suture  is  almost  complete. 
This  is  the  point  at  which  the  char- 
acter of  the  stitch  changes,  as  shewn 
in  next  illustration. 


Fig.  207. — The  inner  through- 
and-through  suture  is  changed  here. 
The  needle  having  reached  the  mu- 
cous surface  of  the  left  opening  is 
passed  in  on  this  side  again  from 
mucous  to  serous  surface.  Then  on 
the  right  side  it  passes  from  serous  to 
mucous  and  back  from  mucous  to 
serous  surfaces,  so  that  a  loop  is 
always  left  on  the  mucosa. 


taken  in  the  mesentery,  and,  finally,  the  needle  is  passed  through 

the  mesentery  to  the  deeper  (or  posterior)  side,  where  it  meets 

the  end  originally  left  long.    The  two  ends  are  tied  and  cut  short. 

A  perfect  apposition  results.     The  weak  point  in  the  suture- 


ENTERECTOMY. 


449 


line — the  gap  at  the  mesentery — is  strengthened  by  both  stitches, 

and  a  leakage  is  virtually  impossible. 
Throughout  the  whole  procedure 

of   suture  introduction  the  greatest 

neatness,  precision  and  fineness  must 

be   exercised,   for   here,    more  than 

anywhere,  the  surgeon's  reward  is 

in  strict  proportion  to  his  deserts. 

A  faulty  suture  will   always  cause 

leakage;    nothing   can    prevent    its 

doing  so ;  a  suture  properly  applied 

will  secure  perfect  union. 

The   slit    in  the   mesentery  has 

now  to  be  closed,  and  the  bleeding 

points  in  the  cut  edges  to  be  ligated. 

It  is  generally  advised  that  athrough- 

and-through  stitch  should  be  used  to 

close  the  mesenteric  wound,  but  I 

have  found  such  stitches  a  source, 

not    infrequently,    of    trouble.       A 

small  vessel  may  be  punctured  and 

a  hsematoma  rapidly  forms,   or  at 

any  point  where  the  needle  punc- 
tures some  haemorrhage  may  be 
started.  I  have,  therefore,  ceased 
to  use  sutures  in  the  mesentery. 
The  plan  I  adopt  is,  to  tie  any 
bleeding  point  in  the  cut  edge  of 
the  mesentery,  and  in  the  same 
ligature  to  include  subsequently 
the  exactly  opposing  point  in  the 
opposite  cut  edge.  This  is  done 
at  each  point  where  a  clip  had  been 
placed,  and  if  the  ligatures  are 
not  sufficiently  close,  a  clip  is  in- 


Fig.  208. — The  inner  suture 
continued.  Note  the  loop  always 
on  the  mucosa.  When  the 
stitch  is  tightened  the  cut  edge 
of  the  mucosa  is  infolded  and 
serous  apposition  secured. 


.-y-- 


Fig.  209. — End-to-end  anastomo- 
sis continued. 


-29 


450  ABDOMINAL   OPERATIONS. 

troduced  on  the  cut  edge  of  one  side,  a  ligature  applied,  the 
clip  removed  and  at  once  put  upon  the  corresponding  point  in 
the  opposite  edge,  which  is  then  taken  in  the  same  ligature. 

In  cases  of  growth  in  the  mesentery,  when  the  removal 
of  the  growth  involves  the  destruction  of  the  blood-supply  to 
the  intestine,  a  resection  of  the  gut  cannot  be  avoided.  So 
much  of  the  bowel  must  be  removed  as  seems,  in  each  case, 
to  be  necessary.  As  a  rule,  there  is  no  difficulty  in  seeing  w^hat 
the  limits  of  such  a  resection  must  be,  though  to  one  unac- 
customed to  this  branch  of  surgery,  the  extensive  removal 
may  seem  surprising.     The  mesentery  may  be  likened  in  its 


Fig.  2IO. — End-to-end  anastomo-  Fig.     211. — End-to-end      anastomosis 

sis  continued.  continued. 

shape  to  an  open  fan,  the  smaller  end  representing  the  pos- 
terior attachment.  This  attachment  is  approximately  six  to 
eight  inches  in  length,  whereas  the  intestinal  attachment  of 
the  mesentery  is  eighteen  feet  in  length.  A  small  wound  in 
the  posterior  portion  of  the  mesentery  leaves  perhaps  several 
feet  of  the  gut  bereft  of  its  blood-supply.  A  small  wound  in 
the  terminal  branches  of  the  superior  mesenteric  artery  is  in- 
evitably followed  by  gangrene  of  the  bowel.  If  the  wound  be 
in  the  second  series  of  vascular  arches,  it  is  possible  for  the 
circulation  to  be  carried  on  through  the  free  lateral  anastomoses. 
Resection  for  Tuberculous  Disease  of  the  Intestine. — Tuber- 


ENTERECTOMY. 


451 


culous  stricture  of  the  intestine  possesses  many  points  of  espe- 
cial interest.  The  disease  is  far  from  uncommon;  it  affects 
the  sexes  indifferently,  and,  owing  to  the  fact  that  fibrous 
hyperplastic  changes  are  frequent,  a  mistaken  diagnosis  of 
carcinoma  may  be  made.  The  favourite  sites  of  the  disease  are 
the  lower  end  of  the  ileum  and  the  caecum;  multiple  strictures 
may  exist  close  together,  or  they  may  be  scattered  at  irregular 
intervals  over  several  feet  of  the  small  intestine.  When  the 
ileocascal  region  is  affected,  a  diagnosis  of  chronic  appendicitis 


Fig.  212. — End-to-end  anasto- 
mosis continued.  Ligature  of  op- 
posing points  in  the  divided 
mesentery. 


Fig.   213. — End-to-end   anastomosis; 
the  operation  concluded. 


or  of  malignant  disease  may  be  made.  The  fullest  and  most 
accurate  account  of  this  disease  is  that  given  by  Mr.  F.  M.  Caird 
in  the  "Scottish  Medical  and  Surgical  Journal,"  vol.  xiv,  p.  20, 
and  I  therefore  quote  at  length  from  this  article : 

"The  clinical  features  in  the  cases  under  consideration 
present  a  long  history  of  failing  health  and  indigestion  associated 
with  progressive  emaciation.  A  personal  and  family  history 
of  tubercle  can  generally  be  obtained.  The  bowels  are  usually 
constipated,    and    purgatives    are    generally    required.     Severe 


452  ABDOMINAL   OPERATIONS. 

colic,  pain,  and  tenderness  become  gradually  pronounced.  A 
salient  feature  is  the  presence  of  loud  borborygmi,  which  not 
only  annoy  the  patient,  but  are  frequently  audible  to  bystand- 
ers. \^omiting  may  be  frequent  and  often  gives  relief.  Haem- 
atemesis  is  not  met  with,  nor  the  passage  of  blood,  although 
piles  may  co-exist.  The  abdomen  becomes  swollen  and  tense. 
Ladder-like  patterns  and  marked  peristaltic  waves  are  seen. 
A  tumour  may  be  palpated  in  ileocsecal  cases.  Owing  to  the 
site  of  the  lesion,  complete  obstruction  does  not  readily  occur, 
unless  the  stricture  becomes  impermeable  and  is  blocked  with 
some  foreign  body,  or  is  complicated  by  adhesions  to  adjacent 
coils  of  intestine. 

"The  principles  common  to  enterectomy  for  malignant 
disease — gangrene  of  the  bowel,  etc. — guide  us  in  dealing  with 
tubercular  stricture,  but  the  operative  measures  are  frequently 
more  difficult,  and  this  is  especially  the  case  when  we  have  to 
deal  with  adhesions.  One  may  shell  a  loop  of  intestine  affected 
with  carcinoma  from  out  a  mass  of  surrounding,  dense,  in- 
flammatory tissue,  as  in  cases  of  adherent  csecal  and  sigmoid 
tumour;  but  in  tubercle  there  is  greater  infiltration,  and  while 
carcinoma  may  be  shut  in  by  the  new  fibrous  tissue,  the  tuber- 
culous process  frequently  bursts  through  the  muscular  and 
serous  coats  and  infiltrates  widely. 

"The  free,  non-adherent  strictures  of  the  small  intestine 
give  rise  to  less  trouble,  but  in  any  case  an  anxious  element 
exists  in  the  wide-spread  implication  of  lymphatic  glands, 
which  may  necessitate  a  far-reaching  removal  of  mesentery 
and  entail  the  sacrifice  of  healthy  intestine.  Or,  again,  some 
of  the  caseating  glands  may  have  softened  or  suppurated,  and 
may  rupture  into  the  peritoneal  cavity  during  manipulation, 
and  so  determine  a  fatal  issue.  In  operating,  then,  let  the 
patient  be  suitably  prepared,  cut  wide  of  the  diseased  area, 
and  see  that  the  distended  intestine  above  the  stricture  be 
thoroughly  emptied.  It  is  always  important  to  plant  the 
sutures  in  healthy,  non-congested  bowel. 

"We  have  three  classes,  which  may  be  treated  as  follows: 

"t.  If   the    strictured   area   be   non-adherent,    be   localised  , 
and  solitary,  divide  well   above  the  proximal  dilated   portion, 
since  there    is  a  tendency  for  development  of    secondary   tu- 
bercle  at  points   of  erosion  and  ulceration  above  the  primary 


EXTERECTOMY.  453 

lesion.  Always  search  for  other  strictures.  Should  there  be 
multiple  strictures  separated  by  a  lengthy  interval  of  healthy 
intestine,  without  glandular  implication,  it  is  better  to  deal 
with  each  stricture  individually  than  to  excise  an  undue  length 
of  the  alimentary  canal. 

"2.  In  dealing  with  an  area  of  coils  matted  to  each  other, 
it  is  advisable  to  ascertain,  in  the  first  place,  the  extent  and 
relation  of  the  parts  involved.  One  next  carefully  identifies 
the  free,  healthy  proximal  and  distal  intestine,  and,  applying 
clamps,  pfoceeds  to  remove  the  entire  mass.  The  mesenteries 
may  be  divided  close  to  their  origins,  as  this  entails  the  Hga- 
tion  of  few-er,  if  larger,  vessels,  and  allows  one  to  remove  all 
the  lymphatic  glands.  As  already  indicated,  since  the  latter 
cannot  well  be  dissected  out  without  damage  to  the  blood- 
supply  of  the  intestine,  it  may  be  necessar}^  to  remove  much 
bowel  in  clearing  away  the  infected  glands.  Should  the  mass 
at  any  point  be  firmly  adherent  at  one  point  to  an  adjacent 
healthy  loop,  it  w^ould  appear  needful  to  excise  the  implicated 
wall  of  that  loop  and  so  avoid  the  possibility  of  leaving  a  future 
focus  of  disease. 

"  3 .  When  there  are  numerous  adhesions  of  coils  not  only 
to  each  other,  but  also  to  adjacent  strictures,  so  that  the  mass 
cannot  be  liberated  without  grave  risk,  it  might  be  safer  to 
sever  the  healthy  proximal  and  distal  coils  of  gut,  and  unite 
them  end  to  end.  The  divided  lumina  in  connexion  with  the 
diseased  area  may  now  be  conducted  externally,  so  as  to  open 
on  the  abdominal  w^all.  Had  this  method  of  complete  oc- 
clusion been  practised  in  one  of  the  cases,  the  patient's  life 
might  have  been  saved,  and  the  tuberculous  area  thus  left 
in  situ  might  have  undergone  atrophy,  or  might  have  been 
removed  at  a  later  date,  under  more  favourable  circumstances. 
It  is  also  probable  that  a  short-circmting  by  lateral  anastomosis 
may  occasionally  give  better  results,  as  has  been  found  by 
others,  but,  on  the  w^hole,  radical  measures  are  usually  to  be 
favoured." 

ih)  Resection  of  the  Intestine  in  Cases  of  Acute  Obstruction 
or  in  Cases  of  Strangulated  Hernia. — Gangrene  of  the  intestine 
as  the  result  of  strangulation  within  the  abdomen  or  in  a  her- 
nial sac  depends  in  part  upon  the  tightness  of  the  constriction, 


454  ABDOMINAL   OPERATIONS. 

in  part  upon  the  virulence  of  the  micro-organisms  which  are 
present  in  the  ensnared  loop.  An  examination  of  the  parts 
in  such  cases  will  shew  that  the  acute  infective  process  is  most 
intense  in  this  loop,  but  that  it  is  by  no  means  confined  solely 
to  it.  The  acute  inflammation,  leading  on  to  ulceration  or  even 
gangrene,  and  the  bacterial  invasion  of  the  coats  of  the  bowel 
extend  upwards  and  downwards  in  the  bowel,  but  to  a  greater 
length  and  to  a  much  more  severe  degree  in  the  part  above  the 
constriction  than  in  that  below.  In  all  resection  operations 
undertaken  for  gangrene  it  is,  therefore,  necessary  to  cut  through 
the  bowel,  on  each  side,  wide  of  the  gangrenous  portion,  but, 
especially,  to  remove  freely  on  the  upper  side.  The  extent 
to  which  the  bowel  should  be  removed  is  not  always  easy  to 
determine,  for  the  gut,  after  division  of  the  constriction,  may, 
from  a  seemingly  hopeless  condition,  slowly  change  its  appear- 
ance and  become  almost  normal.  In  all  these  cases,  there- 
fore, the  intestine  should  be  subject  to  the  most  careful  exami- 
nation, and  the  condition  of  the  vessels  of  supply  in  the  mesen- 
tery be  determined.  If  the  veins  are  thrombosed,  and  if  the 
arteries  have  ceased  to  beat,  the  bowel,  though  it  may  recover 
its  colour  and  appearance  after  release  of  the  constriction,  is 
probably  not  in  a  satisfactory  condition  for  suture.  In  several 
recorded  cases,  and  in  some  few  observed  by  myself,  an  enterec- 
tomy  performed  in  such  circumstances  has  failed  by  reason 
of  gangrene  and  leakage  at  the  line  of  suture  or  from  gangrene 
and  perforation  in  the  proximal  portion  of  the  bowel.  It  is 
better  to  err,  if  an  error  must  be  made,  on  the  side  of  free  re- 
moval. It  is  not  the  length  of  the  bowel  removed  in  these  cases 
which  makes  the  operation  hazardous,  for  two  feet  of  the  in- 
testine are  removed  as  easily  as  two  inches,  but  the  inadequate 
removal  of  bowel  seriously  damaged  and  gravely  infected,  with 
vessels  thrombosed,  and  the  performance  of  an  end-to-end  anasto- 
mosis in  a  part  of  the  bowel  which  cannot  heal. 

The    removal  of   the    bowel,  therefore,  must    be  free,  espe- 


ENTERECTOMY.  455 

cially  upon  the  upper  side.  The  anastomosis  of  the  divided  ends 
is  carried  out  in  the  manner  already  described. 

It  is  especially  in  these  cases  of  overdistension  of  the  intes- 
tine as  the  result  of  acute  intestinal  obstruction  that  the  device 
already  mentioned  of  emptying  the  intestine  is  of  greatest  ser- 
vice. The  clamps  on  the  lower  side  of  the  gangrenous  loop  are 
first  applied  and  the  bowel  is  divided  between  them.  The  prox- 
imal portion  of  the  bowel  is  then  freed  from  its  mesentery  to  a 
degree  which  will  permit  its  being  drawn  away  from  the  wound 
for  six  to  eight  inches.  The  clamp  which  closes  its  end  is  then 
removed,  and  the  gut  allowed  to  empty  itself  of  air  and  fluid 
motion.  The  bowel  above  the  obstruction  is  emptied  by  "milk- 
ing" until  the  overdistension  is  completely  relieved.  The  clamps 
are  then  applied  above,  and  the  diseased  bowel  removed.  The 
removal  of  the  mesentery  to  the  same  extent  as  in  cases  of 
growth  is  not  necessary.  The  method  shewn  in  the  diagrams 
annexed  (Figs.  214  and  215)  may  be  followed. 

The  length  of  the  small  intestine  in  man  varies  greatly,  so 
that  a  standard  measurement  cannot  be  assigned  to  it.  It  varies 
according  to  the  height  of  the  individual  and  according  to  his  na- 
tionality. The  intestine  in  Russians  and  in  Italians  would 
seem  to  be  longer  than  in  the  other  races  in  Europe ;  this  is  doubt- 
less due  to  the  different  character  of  their  food.  In  those  who 
live  largely  or  entirely  upon  bulky  vegetable  foods  a  greater 
length  of  intestine  is  found.  Beneke,  after  comparing  the  height 
of  the  individual  and  the  length  of  the  intestine  in  a  series  of  cases, 
stated  that  for  every  100  cm.  of  body  length,  there  is,  on  the  av- 
erage, 387.5  cm.  of  small  intestine. 

In  discussing  the  question  of  removal  of  great  lengths  of  the 
small  intestine  it  is,  therefore,  not  of  so  great  importance  to  know 
the  amount  of  the  bowel  removed  as  it  is  to  know  the  length  of 
the  bowel  which  remains.  The  extreme  variations  in  the  length 
of  the  small  intestine  are  said  to  be  15  feet  and  33  feet.  The 
average  length  is  given  by  Treves  as  22  feet  5  inches  (683  cm.). 
A  patient  whose  intestine  was  30  feet  in  length  would,  therefore. 


456 


ABDOMINAL   OPERATIONS. 


be  able  to  submit  to  a  more  extensive  resection  than  a  patient 
whose  intestine  was  20  feet  in  length,  or  perhaps  even  less  than 


Fig.   214. — Enterectomy.     The  mesentery  is  ligated  off  close  to  the  gut  (after 

Kocher). 


Fig.   215. — Enterectomy — folding  of  the  mesentery  (after  Kocher). 


this.     Furthermore,  the  functional  activity  of  the  remaining  in- 
testine is  of  the  first  importance.     If  the  gut  which  remains  is 


ENTERECTOMY.  457 

thin  and  atrophied,  as  the  result  of  being  on  the  distal  side  of 
a  long-standing  obstruction,  or  if  the  coils  of  the  bowel  are  in- 
timately adherent,  then  the  value  to  the  patient  of  such  intestine 
is  not  represented  accurately  by  a  mere  statement  of  its  length. 
It  would  seem  possible  that  the  age  of  the  patient  is  also  a  factor 
of  importance,  the  intestinal  canal  in  young  patients  being  better 
able  to  undergo  compensatory  changes.  In  Ruggi's  case  330  cm. 
were  successfully  removed  from  a  boy  eight  years  of  age;  and 
in  Blayney's  case,  255  cm.  from  a  bo}^  of  ten.  In  this  connexion 
it  may  be  mentioned  that  in  Monari's  experiments,  as  in  Senn's, 
it  was  found  that  in  the  dogs  which  shewed  no  intestinal  disturb- 
ance after  operation  a  well-marked  hypertrophy  of  the  intestine 
was  found.  There  is  no  ascertained  difference  in  the  results  which 
follow  removal  of  the  jejunum  from  those  which  are  found  after 
resection  of  the  ileum.  Viewed  from  the  standpoint  of  the  physi- 
ologist, it  might  be  expected  that  excision  of  say  half  the  small 
intestine  at  the  jejunal  end  would  result  in  more  serious  conse- 
quences than  a  similar  excision  at  the  iliac  end.  Diliberti-Herbin 
("Zent.  f.  Chir.,  "  1904,  No.  4)  found  no  difference  in  the  digestive 
capacity  in  two  dogs  who  had  lost  one-half  of  the  small  intestine, 
the  upper  half  having  been  removed  in  one,  and  the  lower  half 
in  the  other.  Observations  were  continued  for  ninety-three 
days,  and  though  at  first  there  was  marked  lack  of  assimilation 
both  of  the  nitrogenous  material  and  of  fat,  the  dogs  soon  began 
to  gain  in  weight,  and  both  recovered  perfectly. 

These  observations  do  not  agree  with  those  of  TrzebiclvV', 
quoted  by  Blayney  ("Brit.  Med.  Jour.,"  1901,  ii,  1456),  whose 
conclusions  as  a  result  of  28  extensive  resections  of  the  small  in- 
testine performed  on  animals  were  as  follows : 

Resections  of  half  the  small  intestine  were  tolerated  quite 
well.  Resections  of  two-thirds  and  upwards  of  the  jejunum  and 
ileum  made  such  an  inroad  on  the  chemical  and  mechanical  pro- 
cesses of  digestion  that  the  prolongation  of  life  became  impossible. 
There  was  incessant  diarrhoea,  followed  at  a  later  stage  by  vomit- 
ing; food  was  voided  for  the  most  part  undigested,  and,  in  spite 
of  a  craving  appetite,  the  animals  perished  with  symptoms  of 


458  ABDOMINAL   OPERATIONS. 

complete  inanition.  Trzebicky  also  observed  that  the  effects 
of  the  resection  of  the  beginning  of  the  jejunum  were  more  seri- 
ous than  those  of  resection  nearer  the  ileocaecal  valve — a  result 
to  be  expected  considering  the  wider,  thicker,  and  more  vascular 
condition  of  the  jejunum.  Transferring  his  results  to  the  human 
subject  and  taking  560  cm.  fi8  feet  5  inches)  as  the  minimum 
length  of  the  small  intestine,  he  declared  that  resection  of  one- 
half  of  it — that  is,  280  cm.  (9  feet  23^  inches) — was  quite  per- 
missible, provided  no  further  complications  were  present. 

The  changes  which  have  been  noticed  subsequent  to  the  re- 
moval of  great  lengths  of  the  small  intestine  are  fairly  constant. 
The  appetite  is  always  greatly  increased;  the  patients  eat  far 
more  than  they  have  ever  done  before.  Diarrhoea  is  a  constant 
feature  for  long  periods,  and  though  it  can  be  controlled  to  a 
certain  degree  by  careful  supervision  of  the  diet,  it  is  apt  to  occur 
on  the  smallest  provocation ;  a  milk  diet  seems  particiilarly  likely 
to  excite  irritation.  In  a  few  cases  (e.  g.,  Pauchet's,  in  which 
400  cm.  were  removed  and  only  125  cm.  remained)  the  diarrhoea 
has  led  to  gradually  increasing  inanition  and  death.  In  a  few 
cases  the  patients  have  gained  weight. 

There  have  been  very  few  investigations  into  the  metabolic 
changes  in  these  cases.  The  only  recorded  cases  are  those  of 
Frantino  (Riva-Rocci) ,  Ruggi  (Sabina),  Schlatter  fPlaut), 
Lexer  (Albu),  and  especially  by  Zusch  ("Deut.  med.  Woch.," 
1909,  p.  739),  Miyaki  (Onodera  and  Jano),  Nigrisoli  (Vitali), 
Zeidler  (Spassokukozkaja),  Axhausen  (Brugsch),  Flint  fUnder- 
hill),  Brenner  (Denk).  They  shew  that  absorption  of  fat  and  of 
nitrogenous  foods  is  considerably  lessened  at  first,  but  that  this 
may  be  compensated  for  by  an  increased  intake  and  by  careful 
regulation  of  the  food-stuffs.  Emaciation  is  common  at  the 
first,  and  is  due  to  the  rapid  passage  of  food,  from  which  little 
absorption  has  taken  place,  through  the  intestine.  But  when  a 
very  large  amount  of  judiciously  selected  food  is  taken  the  weight 
of  the  patient  gradually  increases. 

The  outcome  of  a  study  of  those  recorded  cases  would  seem 
to  shew  that  a  removal  of  two-thirds  of  the  small  intestine  may 


ENTERECTOMY.  459 

be  performed  in  the  human  being  without  serious  risk  to  hfe. 
The  remaining  third  is  adequate  to  fulfil  all  the  functions  neces- 
sary to  the  maintenance  of  life,  provided  that  it  is  healthy  and 
that  care  is  taken  in  the  selection  of  the  diet. 

The  surgeon  who  is  suddenly  face  to  face  with  a  case  requiring 
an  extensive  intestinal  resection  usually  has  no  choice  as  to  what 
has  to  be  done. 

A  glance  through  the  recorded  cases  will  shew  that  the  bowel 
involved,  either  in  gangrene  or  in  growth,  had  instantly  to  be 
sacrificed  if  the  patient's  life  was  to  be  saved.  In  nearly  every 
case  death  would  have  resulted  had  the  resection  not  been  per- 
formed. To  be  niggardly  in  the  removal  of  gangrenous  intestine 
is  to  detract  enormously  from  a  patient's  chances  of  recovery,  for 
in  such  cases  an  anastomosis,  to  succeed,  must  be  made  between 
healthy,  viable  ends  of  intestine.  The  cases  quoted  in  the  table 
shew  clearly  enough  that  the  most  extravagant  sacrifice  of  intes- 
tine may  safely  be  made  when  an  imperative  necessity  for  doing 
so  has  arisen.  The  most  extensive  resection  ever  carried  out  on 
a  human  being  was  performed  by  Brenner;  540  cm.  of  the  ileum 
were  removed  from  a  woman  aged  sixty-one,  for  gangrene  due  to 
torsion  of  the  intestine  in  a  large  femoral  hernia.  The  patient 
made  an  excellent  recovery,  and  shewed  but  little  disturbance  of 
her  metabolism.  She  had  about  five  fluid  stools  a  day,  which  were 
bad  smelling  and  contained  much  undigested  food.  Later  con- 
ditions improved,  and  Denk  made  a  test  of  the  functional  effi- 
ciency of  the  intestine  by  Schmidt's  method,  which  indicated  a 
normal  digestion.  About  one  and  one-half  years  after  the  opera- 
tion Denk  repeated  the  test.  At  this  time  she  had  from  three  to 
four  soft  or  fluid  stools  a  day,  the  latter  condition  occurring  par- 
ticularly after  taking  much  coffee  or  milk.  Although  there  was 
a  diminished  fat  absorption,  the  patient  maintained  her  weight 
and  was  able  to  do  her  housework  without  fatigue.  Otherwise 
the  metabolism  was  perfectly  normal. 

A  subsequent  report  on  this  case  made  by  Denk  recently 
shews  the  importance  of  a  guarded  prognosis  even  in  apparently 
successful  cases  of  extensive  resection  of  the  small  intestine.     A 


460  ABDOMINAL  OPERATIONS. 

year  after  the  last  report  was  published,  or  two  and  one-half 
years  after  the  operation,  the  patient  died  of  marasmus.  At 
the  time  of  operation  the  patient  weighed  48  kilos,  and  just  be- 
fore death,  26^2  kilos.  There  was  a  general  atrophy  of  all  the 
organs,  particularly  of  the  omentum  (Marshall  Flint). 

The  reader  who  is  interested  in  this  subject  is  referred  to  an 
excellent  paper  by  Professor  J.  M.  Flint,  "Bull.  Johns  Hopkins 
Hospital,"  1912,  xxiii,  p.  127. 

SOME  INDICATIONS  WITH   REGARD  TO  AFTER-TREAT- 
MENT IN  CASES  OF  EXTENSIVE  INTESTINAL 
RESECTIONS. 

1.  The  diet  should  be  rich  in  nitrogen  and  easily  assimilated. 
Examples,  sweetbreads,  liver,  white  meats,  sheep-brains,  etc. 

2.  It  should  not  contain  too  great  a  percentage  of  fats,  which 
are  badly  assimilated  in  these  cases. 

3.  Carbohydrates  in  an  easily  digestible  form  should  be 
given  in  increased  quantities.  Sugar  in  good  quantity, 
especially  powdered  glucose. 

4.  Astringents  may  be  used,  and  also  intestinal  antiseptics,  as 
bismuth,  in  i-drachm  doses,  t.  d.  s.,  with  lo-grain  doses 
of  salol. 

5.  There  should  be  no  restriction  of  fluids. 

Experimental  evidences  and  metabolic  investigations  on  op- 
eration cases  shew  that : 

(a)  There  is  a  decreased  digestion  of  nitrogenous  food  and 
consequently  nitrogenous  starvation. 

(b)  There  is  a  decreased  digestion  of  fatty  foods. 

{c)  Carbohydrate  digestion  is  but  slightly  interfered  with; 
hence  the  necessity  of  a  diet  largely  composed  of  carbohy- 
drate food. 
(d)  Owing  to  the  facts  that  foods  taken  arrive  at  the  large  in- 
testine in  a  shorter  period,  and  therefore  less  adequately 
digested  than  is  normal,  and  that  they  remain  for  the 
normal  period  in  the  large  intestine,  there  is  increased  in- 
testinal putrefaction  due  to  the  food  remaining  under 
these  altered  conditions,  exposed  to  the  action  of  bacteria 
in  the  large  intestine.  Hence  the  necessity  for  intestinal 
antiseptics. 

Conclusions 
These  patients  should  have  a  rich  and  easily  assimilated  diet, 
poor  in  fats,  and  relatively  rich  in  carbohydrates.     Bismuth  as 
a  colonic  antiseptic  should  be  tried  with  or  without  salol. 

The  following  table  gives  all  the  recorded  cases  of  resection 
of  great  lengths  of  the  intestine. 


U 
W 

CD 

w 
Pi 

< 

CD 
W 

H 


After  Condition,  or  Cause  of 
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Seven  years  later  condition  good, 
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Since  operation,  thin,  pulpy  stools, 
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daily,  these  often  effusive. 

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Intestinal  fistula  healed  when  the 
Murphy  button  came  away  four 
months  later. 

Good  health  eight  months  later; 
taking    ordinary    peasant    food, 
with   normal  digestion  and   de- 
faecation. 

Death  three  weeks  after  operation; 
autopsy    showed    advanced    tu- 
berculosis of  lungs,  and  abscesses 
were  found  in  the  pelvis. 

Recovered   and   went   home   after 
operation.     Some     looseness     of 
stools.     Gradually     lost     weight 
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Recovery. 

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seven 
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ton and  a  few  Lem- 
bert  sutures. 

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tomosis    between 
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Rupture   of   intestine 
and  rent  in  the  mes- 
entery. 

Ventral  hernia,  intes- 
tinal        obstruction 
with  adhesions. 

x!2.22 
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Carcinoma  of  the  cae- 
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mesentery. 

i 

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Enochin:    Ref.  Is- 
tomin,   "Russ. 
med.     Rund- 
schau," 1910, 
viii,  329. 

T3 
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Blayney:      "Brit. 
Med.  Jour.," 
1901,  ii,  1456. 

Lauwers:     "Ann. 
de    la    Soc.    de 
Chir.  (de  Beige)," 
1901,  ix. 

Park:    "Arch.  In- 
ter, de  Chir.,"  i. 
"  Centrabl.  f . 
Chir.,"  1904, 
xxxi,  55,  and 
"Buffalo  Med. 
Jour.,"  1903. 

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Kopf  stein:     "Re- 
vue   de    Bohm. 
Med.,"  1909,  Ref. 
"Wien.  med. 
Bl.,"  1910. 

Maydl,  quoted  by 
Kukula:  "Archiv 
f.  klin.  Chir." 

^Childe:    "Brit. 
Med.  Jour.," 
1901,  ii,  891. 

"Practitioner," 
1909,  cxxxii,  364. 

Lorenz:    "Wien. 
klin.Wchnschr.," 
1906,  xix,  610. 

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After  Condition,  or  Cause  of 
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Ten    and    one-half    months    later 
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power  of  work;     ordinary   food; 
defcccation,  1,2, and  3  times  daily. 
In  1910  quite  well  and  fully  able 
to  work. 

Eats  same  kind  of  food  but  "half 
as  much  again  as  before";   stools 
formed  and  soft;     one  or  some- 
times two  actions  daily.     Heavi- 
est weight  before  operation,  158 
pounds;     now,  146  pounds.     He 
says:    "  I  am  just  as  well  as  ever 
in  my  life." 

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ENTERECTOMY.  469 

This  series  of  cases  shews  clearly  enough  that  the  extent  of 
the  resection  may  be  very  considerable  without  involving  any 
such  serious  risk  as  one  might  expect.  It  emphasises  the  point, 
upon  which  stress  has  already  been  laid,  that  a  free  removal 
of  the  bowel  should  be  performed  in  any  case  where  doubt 
exists  as  to  its  integrity. 

In  certain  cases  the  band  which  has  caused  the  constriction 
has  been  very  narrow  and  has  compressed  the  gut  very  tightly. 
A  fine  linear  band  of  gangrene  is  thereby  produced.  If  this 
band  encircles  the  intestine,  a  resection  operation  is  not  always 
necessary.  The  damaged  strip  may  be  simply  infolded  and 
closed  over  by  a  continuous  suture  which  picks  up  the  serous 
and  muscular  coats.  When  the  gangrenous  part  gives  way, 
it  will  be  shed  into  the  lumen  of  the  bowel  and  the  firm  line  of 
union  ensured  by  the  suture  will  prevent  any  leakage  into  the 
peritoneal  cavity.  In  some  instances  a  very  small  patch  of 
gangrene  or  a  perforation  may  be  met  with.  It  is  in  cases 
such  as  these  that  a  partial  resection  has  been  successfully 
performed.  The  edges  of  the  perforation  are  trimmed  and 
sutures  applied,  or  the  damaged  area  is  inverted.  Caird  has 
recorded  ("Edin.  Med.  Jour.,"  1895,  p.  312)  five  cases  of  gangrene 
or  perforation,  occurring  in  strangulated  hernia,  which  were 
treated  by  inversion.  In  some  cases  of  Richter's  hernia,  with 
gangrene  limited  to  a  A^ery  small  area  opposite  the  mesenteric 
attachment,  this  method  may  be  adopted.  But  it  is  to  be 
remembered  that  the  walls  of  the  bowel  around  the  damaged 
area  are  infected  and  but  little  likely  to  lend  themselves  to 
safe  suture  or  to  sound  healing.  The  operation  of  inver- 
sion, though  occasionally  advisable,  is  probably  not  so  safe  a 
procedure  as  resection. 

In  all  operations  where  the  bowel  has  been  strangulated 
and  has  become  gangrenous  the  most  minute  precautions  must 
be  taken  to  avoid  contamination  of  the  operation  area  in  the 
handling  of  tissues  which  are  infected  with  swarms  of  the  most 
virulent  organisms. 


470 


ABDOMINAL    OPERATIONS. 


In  some  instances  the  use  of  an  omental  flap  or  graft  is  of 
great  ser\4ce  in  strengthening  the  hne  of  union. 

In  both  the  operations  above  described  the  removal  of 
a  triangular  piece  of  the  mesentery  is  desirable,  for  in  cases  of 
gro-^-th  the  glands  are  included  in  it,  and  in  cases  of  gangrene, 
the  vessels  in  the  mesentery  are  seriously  damaged,  and  the 
veins  perhaps  filled  with  septic  clots. 

In  cases  of  multiple  wounds  of  the  intestine  or  in  other 
rarer  conditions  the  removal  of  this  triangular  piece  of  the 
mesentery  is  not  necessar\'.     The  mesentery  quite  close  to  the 

bowel  may  be  cut  through 
along  a  line  parallel  to  the 
intestine,  and  the  bleeding 
points  clipped  and  ligated. 
When  the  ends  of  the  intes- 
tine are  stitched,  the  mesen- 
tery' can  then  be  folded  upon 
itself  in  a  pleat.  It  is  said 
that  in  such  a  condition  the 
suture -Hne  at  the  mesenteric  gap  is  hkely  to  be  more  securely 
closed  than  when  the  mesentery  is  removed.  Sir  William  ]\Iac- 
Cormac  also  claimed  for  this  method  that,  since  it  interfered  less 
with  the  vessels  of  the  mesentery  (the  terminal  branches  onlv 
being  cHppedj,  gangrene  of  the  bowel  was  far  less  likely  to 
occur  than  when  the  deeper  vessels  of  the  mesentery  were  ligated. 
(See  Figs.  214  and  215.)  It  is  perhaps  desirable  to  call  attention 
to  a  very  satisfactory  stitch,  introduced  by  ]\Iitchell  and  Hunter, 
for  the  purpose  of  effectively  closing  the  gap  at  the  mesen- 
teric edge.     The  diagram  (Fig.  216)  explains  itself. 


Fig.  216. — Mitchell  and  Hunter's 
suture  for  application  at  the  mesenteric 
attachment. 


INDEX  OF  NAMES— VOLUME 


Abbe,  io6 
Adossides,  131 
Albrecht,  94 
Albu,  458,  461 
Allis,  184,  186 
Andrews,  52 
Angelberger,  206 
Anschiitz,  237,  238 
Archibald,  135 
Assmy,  106 
Auvray,  372 
Axhausen,  458,  462,  468 

Ballance,  391 

Bancock,  407 

Barclay,  261 

Barker,  214,  215 

Barnard,  145,  146 

Bartlett,  210,  211 

Bastianelli,  160 

Battle,  221,  236 

Baudens,  371 

Beckman,  100 

Bell,  63,  72 

Beneke,  455 

Bernard,  20,  206 

Bertram,  373 

Beyea,  155,  156,  157 

Beyer,  162 

Biburgeil,  77 

Bier,  157 

Billroth,  17,  160,  206,  315 

Bingham,  230 

Blake,  123,  124,  127 

Blayney,  457,  463 

Borchgrevink,  131 

Borrmann,  290,  299,  300 

Bosquier,  85 

Box,  92,  95 

Braithwaite,  230,  231,  232 

Braun,  209,  217,  363 

Brenner,   208,   270,  45S,  459,  462, 

Briddon,  374 


468 


Brinton,  300,  336 

Brougham,  466 

Brugsch,  458,  468 

Bryant,  428 

Bucknall,  80,  81,  82,  83,  84 

Bucquoy,  174 

Buxton,  126 

Cackovie,  363 

Caird,  451,  469 

Cannizaro,  371 

Cantani,  157 

Carle,  238,  298,  300,  328 

Carrion,  95 

Chaput,  209,  270 

Childe,  463 

Chlumskij,  205,  206,  207,  208 

Clark,  36,  55,  65,  161,  162 

Claudius,  34,  35 

Coflfey,    153,    154,    204,    205,    266,    270, 


272,  273,  274,  283, 
Coley,  117 
Collin,  1 74 
Connell,  391,   39; 

398,  404 
Conner,  95 
Cordier,  98,  99 
Courvoisier,  208 
Crile,  42,  43,  62,  235 
Cripps,  421 
Cuneo,    290,    292,    294 

300,  330 
Cushing,  18,  19,  20,  2 
Czerny,  106,  131,  207 

Dastre,  206 
Davies-Colley,  174 
Davis,  152 
Dekonski,    462 
Denk,  458,  459,  462 
Depage,  154 
Diaz,  85 
Diliberti-Herbin,  457 


184 


393.   395.   396,   397. 


295,    298,    299, 
2,  38,  263.  3S7 


471 


472 


INDEX   OF   NAMES VOLUME   I 


Dobson,  290,  293,  294,    295,  298,  299, 

301 
Domenici,  18,  19 
Douglas,  115,  116 
Doyen,  207,  209 
Dreesmann,  461 
Dudensing,  174 
Dupuytren,  385,  386,  3S7 
Duret,  150,  151 
Dwight,  379 
Dyball,  80 

Edgecombe,  228 
Edmunds,  391 
Edwards,  106 
Eiselsberg,  87,  88 
Enderlen,  461 
Enochin,  462 
Escherich,  17 
Ewart,  94 

Fagge,  93 

Fantino,  238,   298,   300,  328,  458,  464 

Faure,  158,  209 

Fenner,  117,  118 

Fenwick,  344 

Finney,   170,   242,   245,    246,   247,   248, 

249,  251,  252,  280,  311 
Fischel,   85 
Flint,  458,  460,  465 
Foote,  278 

Forgue,  369,  371    372,  373,  374 
Francke,  161 
Frank,  360,  361 
Friedrich,  467 

Gabzewicz,  374 
Gatti,  135 

Gerard-Marchant,  160 
Gerota,  290,  291 
Ghedini,  464,  468 
Gibson,  405 
Gilbert,  18,  19,  20 
Gillespie,  18 
Girode,  84,  85 
Glenard,  150 
Goebell,  464 
Gordon,  216 
Grant,  100 
Gray,  212 
Gross,  174,  387 


Griineisen,  142 
Guinard,  370 

Hadra,  210,  363 

Hahn,  67 

Hall,  218 

Hallon,  95 

Halm,  363 

Halsted,  385,  386,  387 

Hanau,  82 

Harrington,  39 

Harris,  462,  463 

Hartmann,  106^  257,  290,  368,  444 

Hayes,  462 

Herczel,  205 

Hertz,  238 

Herzf  elder,  174 

Hildebrandt,  136 

Hochenegg,  197 

Hofbauer,  67 

Hoffman,  174 

Hoffmann,  22 

Howse,  106 

Hunt,  139 

Hunter,  470 

Hutchinson,  89 

Jaboulay,  208,  209,  240 

Jakob,  67 

Jamieson,  290,  293,  294,  295,  298,  299, 

301 
Jano,  458  465 
Janowski,  85 

Jeanbrau,  369,  371,  372,  373 
Jessop,  94 

Kader,  125,  208,  209,  357,  358,  359 
Kammerer,  252,  279,  280 
Kappeler,  208 
Karlinski,  374 
Karlow,  462,  466 
Kausch,  363 
Keen,  98 
Keetley,  254 
Kelling,  237 
Kelly,  465 
Kerr,  201,  306 
Key,  218 
Keyl,  174 
Kisbert,  160 

Kocher,  27,  29,  106,  iii,  126,  210,  242, 
251,  261,  311,  315,  316,  360,  456,  461 


INDEX   OF   NAMES — VOLUME    I 


473 


Koeberle,  461 

Konig,  133 

Kopfstein,  463 

Korte,  74,  78,   138,   139,  142,  145-  3^3 

Kousnetzoff,  115,  160 

Kou\A'er,  462 

Krauss,  174 

Krehl,  331 

Krokiewicz,  318 

Kronlein,  87,   319,   320,   321,   323,   325, 

327.  328 
Kukula,  462,  463 
Kiimmell,  208,  240,  241 
Kundrat,  94 

Landau,  158 

Langenbeck,  330 

Langenbuch,  160 

Lauenstein,  209,  210 

Lauwers,  463 

Legueu,  160 

Lehmann,  85 

Lembert,  384,  385.  386,  387 

Lemeau,  174 

Lengeinann,  290,  293,  295,  299,  301 

Lennander,  104,  125,  173,  176,  218,  414 

Lilienthal,  430,  431,  432 

Lockwood,  160 

Loewy,  67 

Lorenz,  463 

Loze,  S3 

Liicke,  209 

Lund,  217 

LetuUe,  292 

Levin,  18 

Levy,  330 

Lexer,  458,  460 

MacCarty,  287 
MacCormac,  470 
Macdonald,  332 
Macfadyen,  19 
Malbranc,  206 
Mall,  375 
Marfan,  20 
Margaracci,  131 
Marwedel,  359 
Maunsell,  388,  389,  390,  391 
Maydl,  139,  145,  209,  364,  463 
Mayo,  77,  100,  loi,  136,  190,   196,  197, 
211,    223,    270,    285,    287,    305,    325, 

328,  330 


McBurney,  106,  420 
McCosh,  125 
McGuire,  466 
Meunier,  173 
Michel,  no 

Mikulicz,  67,   68,  69,  71,    77,   143,   205, 
208,  290,  300,  319,  324,  325,  327,  328, 

330.  359-  362,  3(>3'  461 
Miller,  18 

Mitchell,  172,  466,  470 
Mixter,  412 
Miyaki,  68,  458,  465 
Monari,  457 
Monks,   375,   376,    377     378,   379,    3S0, 

381,  382,  383,  411 
Monprofit,  464 
Moore,  344 
Mbrison,  52,  218 
Morley,  85 
Morris,  90,  91,  93 
Morton,  465 
Moschowitz,  35 
Most,  290,  293,  295,  300 
Moynihan,  174,  180,  251 
MuUer,  95 
Murphy,  40,  60,  61,  114,  132,  133,  134, 

136,  172,  404,  435,  463,  467 

Navratil,  290,  293,  294,  295,  298,  301 

Nelaton,   410,   416 

Neumann,  363 

Nicola,  466 

Nigrisoli,  458,  468 

Noble,  III,  465 

Nuttall,  18 

Obalinski,  466 
Oldfield,  166 
Oddi,  206 
Onodera,  458,  465 
Ordway,  94 

Pagenstecher,  35 
Paget,  79,  81 
Park,  463 
Parker,  306 
Pasteur,  74 
Paterson,  218,  261 
Pauchet,  458,  467 
Paul,  412,  417,  41S,  425 
Payr,  463 
Pean,  160 


474 


INDEX   OF   NAMES — -VOLUME   I 


Peck,  463 

Pepper,  93 

Perrin,  206 

Perutz,  139,  142,  144,  145 

Petersen,  20S 

Peterson,  460 

Phillips,  275 

Pilch er,  223,  270 

Pilliet,  82,  31S 

Planchard,  174 

Plant,  45S,  461 

Pokotilo,  463 

Poh'a,  290,  293,  294,  295,  298,  301 

Poncet,  374 

Popofif,  17 

Porritt,  218,  219 

Prantois,  85 

Purves,  87,  88,  89 

Reichard,  90 

Reichel,  317 

Richardson,  98 

Richter,  67,  469 

Riedel,  15S,  159 

Riegel,  206 

Riva-Rocci,  458,  464 

Robinson,  160 

Robson,  89,  176,  365,  367 

Rockwitz,  209 

Rodman,  88,  89,  259,  260,  287 

Rokitansky,  174,  300 

Rorsch,  131 

Rothe,  461 

Roux,  198,  199,  200,  201,  202,  209,  223, 

224,  230,  252,  364 
Rovsing,  152,  154 
Ruggi,  457,  458,  465 
Rutkowsky,  209 

Sabixa,  458 

Sagini,  465 

St.  Martin,  371 

Sappey,  158 

Schlatter,  321,  366,  458,  461,  466 

Schmidt,  459 

Senn,  352,  353,  354,  355,  356,  357,  358, 

360,  457 
Shepherd,  462 
Smith,  371 
Socin,  371 
Sonnenburg,  209 
Spassokukozka j  a ,  458,464 


Spencer.  241 
Staehlin.  464 
Steinthal.  363 
Stengel,  93 

Steudel,  206,  207.  208 
Stewart,  348 
Stolz,  467 
Storp,  466,  468 
Subkovski,  85 
Siimmers,  269 
Swain,  85 

Tait,  54 

Tatlow,  252 

Tavel,  209 

Terrier,  159,  206,  319 

Testa,  85 

Testut,  370 

Thierf  elder,  18 

Thomas,  275 

Thomson,  90,  91,  93 

Thompson,  348 

Thon,  462 

Tiffany,  117 

Toupet,  85 

Treves,  369,  455 

Trzebicky,  457,  458,  461 

Tscheming,  160 

Underhill,  458 

Van  Roojex.  218,  219,  221 

Villard,  208,  240,  242,  244 

VitaH,  458,  468 

von  Eiselsberg,  87,  88 

von  Hacker,  208,  209 

von  Mikulicz,   67.  68,  69,   71,   77.   14J 

205,  208,  290,  300,  319,  324,  325,  32; 

328,  330.  359.  362,  363,  461 
von  Navratil,  290.  293,  294,  295,  29$ 

301 

Wallace,  92.  95 

Ward,  421,  422.  423,  424,  429.  432 

Watson,  2S2 

Webster,  154,  161,  162 

Weil,  205 

Weir,  278,  279,  415 

Wells,  133 

Werelius,  466 

Whitall,  465 


INDEX   OF   NAMES — VOLUME    I 


475 


White,  204,  24S 
Wickhoff,  206 
Wiesinger,  94 
Wiggin,  391,  394 
Wilkie,  89,  218,  221 
Wilms,  317 
Wilson,  loi,  102,  2S7 
Witzel,    125,   209,   252,   254,    358,    359, 
365 


Wolfler,  207,  208,  209,  210,  281,  390 
Wunderlich,  131 

Wyeth,  428 

Yates,  55,  56,  65 

Zeidler,  458,  464 
Zusch,  458,  464 


INDEX  OF  SUBJECTS— VOLUME 


Abdomen,  gunshot  wounds  of,  369 
wounds  of,  penetrating,  114.  See  also 
Penetrating  wounds  of  abdomen 
Abdominal  belt  for  gastroptosis,  150 
for  hepatoptosis,  159 
incisions,  105 

operations,  after-treatment,  24,  57 
conduct  of,  24 
drainage,  54 

examination  after  laparotom)'-,  49 
isolation  of  area,  49 
preparations  for,  24 
time   patient    should   be   kept   in 
bed,  63 
suture,  108,  109 
Abscess  of  lungs  after  operation,  73,  78 
perigastric,  140 

subphrenic,  137.  See  also  Subphrenic 
abscess 
Adhesions,  treatment  of,  51 
After-treatment,  24,  57 
Albumose  injections  to  prevent  post- 
operative peritonitis,  67 
Alimentary  canal,  bacteria  in,  relative 
number,  18,  19 
bacteriology  of,  1 7 
sterility  of,  food  and,  19,  20 
Ancesthesia,  44 
Anaesthetic,  43 
Anastomosis  button,  404 
end-to-end,  405 

in  enterectomy,  445,  446 
lateral,  433.    See  also  Entero-anasto- 
mosis 
Anoci-association,  43,  62 
Antistreptococcic    serum    to    prevent 

peritonitis,  71 
Anus,  artificial,  in  enterostomj',  410 
Aponeurosis,  overlapping  of,  in  abdom- 
inal suture.  III 
Appendectomy     with     gastro-enteros- 

tomy,  221 
Appendicitis,  duodenal  ulcer  and,   174 


Appendicostomy,  415 
Appendix,     adhesions    around,    treat- 
ment, 52 
Artificial  anus  in  enterostomy,  410 
Ascitic  tuberculous  peritonitis,  128 
Aspirin  for  pain,  62 
Assistants,  preparations  of,  31 

Bacillus  coli  in  intestines,  17 
prodigiosus  in  intestine,  19 

Bacteriology  of  intestines,  1 7 
of  stomach,  17 

Bantock's  tube  in  enterotomy,  407 

Beyea's  gastropexy,  155,  156 

Bier's  gastropexy,  157 

Bismuth  for  rendering  intestinal  con- 
tents sterile,  23 

Black  vomit,  86.  See  also  Hcematemesis, 
post-operative 

Brenner's  gastro-enterostomy,  208 

Bronchitis  after  operation,  73,  78 

Bronchopneumonia,  post-operative,  73, 

75.  78   _      _  _ 
Bryant's  incision,  428 
Buried  sutures,  material  for,  iii 

Cancer,  gastric,  285.    See  also  Gastric 
cancer 
jejunal  ulcer  after  operation  for,  218 
of  pylorus,  mode  of  spreading,  297, 
298 
operation  in,  choice,  318 
of  small  intestine,  resection  for,  441 
pylorectomy  for,  318 
Carcinoma.  See  Cancer 
Cardiac    cancer,    choice    of   operation, 

330 
Catgut  for  buried  sutures,  1 1 1 

preparation  of,  34 
Catheterisation  after  operation,  60 
Caustic  fluids,  drinking  of,   ulceration 

from,  254 


4; 


478 


INDEX   OF    SUBJECTS — VOLUME   I 


Celluloid  thread,  Pagenstecher's,  35 
Chlumskij's  gastro-enterostomy,  208 
Choledochotomy,   adhesions  in,   treat- 
ment, 5 1 
Cholelithiasis,  "natural  cure,"  52 
Claudius'  sterilisation  of  catgut,  34 

Moschowitz's    modification,    35 
Cloisonnement     peritoneal    horizontal' 

for  hepatoptosis,  160 
Coeliac  axis,   gastric  lymphatics  asso- 
ciated with,  297 
Coffey's  gastropexy,  153,  154 
Collapse  of  lung  after  operation,  73,  74 
CoUargol  injections  to  prevent  phlebitis, 

104 
Colohepatopexy,  52 
Colon  substitution,  52 
Colotomy,  417 

Bryant's  incision  in,  428 

high  sigmoid,  419 
time  for,  425 

ingmnal,  417,  418 

and  lumbar,  choice  between,  417 
short  mesentery,   430 

Lilienthal's,  430 

low  sigmoid,  425 

lumbar,  417,  418,  428 
drainage  in,  429 
short  colon  in,  429 

Paquelin  cautery  in,  425 

Paul's  tube  in,  417 

sigmoid,  high,  419 
low,  425 

Ward's  suture  in,  421,  422,  429 
Complications  of  abdominal  operations 

66 
Connell's  suture,  391 
Continuous  proctoclysis,  60 

subcutaneous  saline  infusion,  126 
Coronary    artery,    gastric    lymphatics 

associated  with,  292 
Courvoisier's  gastro-enterostomy,  208 
Crile's  anoci-association,  43,  62 
Cushing's  suture,  387 


Davis'  gastropexy,  152 
Diarrhoea  after  enterectomy,  458 
after  gastro-enterostomy,  2  36 

clinical  forms,  237 

theories  of,  237 
Diet  after  operations,  59 


Digital  divulsion  for  hour-glass  stom- 
ach, 283 
Dilatation,  digital,  for  hour-glass  stom- 
ach, 283 
gastric,  post-operative,  90 
pathology,  92 
symptoms,  90 
theories,  93 
treatment,  96 
Divulsion,  digital,  for  hour-glass  stom- 
ach, 283 
Doyen's  gastro-enterostom}-,  209 
Drainage,  36,  54 
care  of  tubes,  64 
material,  36 
Dressing,  6 1 

Drinking  caustic  fluids,   gastric  ulcer- 
ations from,  operation  for,  254 
Drugs  for  rendering  intestinal  contents 

sterile,  22 
Duct-infection    theorj"    of    secondary 

parotitis,  82 
Duodenal  fistula,  external,  174 
internal,  174 
ulcer,  163 

chronic,  infolding  of,  192 

jejunal     ulcer      after      operation, 

cases,  224,  228 
perforating,  173 

appendicitis  and,  174 
consequences,  173 
diagnosis,  175 
fistula  from,  174 
gastro-enterostomy  in,  171,  175 
manner  of,  173 
operation  in,  175 

closure  of  ulcer,  175 
symptoms,  174 
Duodenostomy,  368 

in  cancer,  329 
Duodenum,     invasion    of,     in    gastric 

cancer,  300 
Dupuytren's  suture,  385,  3S6 
Duret's  gastropexy,  150 


Embolic    theory    of    secondary    paro- 
titis, 80 
Embolism,  pulmonary,  after  operation, 

73.  75.  78 
End-to-end  anastomosis,  405 
in  enterectomy,  445.  446 


INDEX   OF   SUBJECTS — VOLUME    I 


479 


Enema  after  operation,  60 
Enterectomy,  440 

after-treatment,  460 

diarrhoea  after,  45 S 

effects  on  digestion,  457 

end-to-end  anastomosis  in,  445,  446 

extension,  460,  461 

for  gangrene,  453 

for  growths,  441 

for   obstruction    in    small    intestine, 

453 
for  strangulated  hernia,  453 
for  stricture,  441 
for  tuberculous  disease,  450 
indications,  440 
length  of  piece  resected,  455 
metabolic  changes,  458 
on  small  intestine,  441 
results,  458 
Entero-anastomosis,  209,  433 
advantages,  434 
indications,  434 
Murphy  button  in,  435 
results,  438 

short  mesosigmoid  in,  439 
techniqtie,  435 
Enteroptosis,  150 
Enterostomy,  410 
adhesions  after,  414 
artificial  anus  in,  410 
isecsd  fistula  in,  410 
for  bowel  evacuation  in  peritonitis, 

125 
indications,  410,  415,  416 
Mixter's  tube  in,  412 
pain  at  discharge  after,  413 
Paul's  tube  in,  412 
site  of  opening,  413,  414 
Enterotomy,  406 

Bantock's  tube  in,  407 

for  bowel  evacuation  in  peritonitis, 

125 
Moynihan's  tube  in,  407 
Eserine  sulphate  for  flatulence,  63 
Excision  for  gastric  cancer,  287 
of  gastric  ulcer,  259 

adherent  to  pancreas,  275 
along  lesser  curvature,  263 
by  rotation  of  stomach,  269 
gastro-enterostomy  and,  choice 

between,  259 
indications,  260 


Excision     of    gastric    ulcer   involving 
large  extent,  266 
on  anterior  wall,  262 
on  posterior  surface,  269,  270 
technical  considerations,  262 
through   transverse   mesocolon, 

270 
transgastric,  269,  270 
Exploratory  incision  in  gastric  cancer, 
mortality,  324 


F.^CAL  fistula  in  enterostomy,  410 
Fallopian   tubes,    involvement   in    tu- 
berculous peritonitis,  134 
Faure's  gastro-enterostomy,  209 
Fibrous    tuberculous   peritonitis,    129, 

130.  131 
Finney's  gastroduodenostomy,  245 
Moynihan's  modification,  249 
Fistula,  duodenal,  external,  174 
internal,  174 

f cecal,  in  enterostomy,  410 
Flatulence,  63 
Floating  lobe,  158,  159 
Formaline-gelatine  for  dressing,  61 

to  prevent  adhesions,  135 
Francke's  hepatopexy,  161 
Frank's  gastrostomy,  360 


Gall-bladder,       adhesions      around, 

treatment,  5 1 
Gangrene  of  intestine,  enterectomy  for, 

453 

inversion,  469 
of  lung  after  operation,  73 
Garments  for  operator,  24 
Gastrectomy,  complete,  332 

after-care,  343 

late  history  of  patient,  347,  348 

microscopical  examination,  346 

pathologic  report,  344 

postmortem,  34S 

technique,  337 

use  of  stomach  tube  in  oesophagus, 

344 
partial,  302 

advantages      over      gastro-enter- 
ostomy, 328,  329 

closure  of  distal  end  of  duodenum, 
306 


48o 


INDEX   OF    SUBJECTS — VOLUME    I 


Gastrectomy,  partial,  feeding  after,  316 
for  cancer,  28 7,  32 S 

mortality,  325 
for  hotir-glass  stomach,  279,  283 
mortality,  319.  321 
Gastric  cancer,  285 
adhesions  in,  52 
cardiac  end,   choice  of  operation, 

330 
diagnosis,  2S6,  2S8 
duodenostomy  in,  329 
exploratory  incision  in,  2 88 

mortality.  324 
gastrectomy  in,  complete,  332 
partial,  302,  328 
mortality,  321,  325 
gastro-enterostomy  in,  327 

mortality,  321,  324 
history,  285 

invasion  of  bowel  in,  300 
of  duodenum,  300 
of  greater  curvature,  299 
of  lesser  curvature,  299 
jejunostomy  in,  329 
local  enlargement,  299 
h^mphatic  invasion,  298 
microscopical  examination,  346 
mode  of  spreading,  297,  298 
mural,  choice  of  operation,  329 
operation  in,  285 

choice,  318,  327,  329 
indications,  288 
mortality,  319,  320 
palliative  or  radical,  319 
pathologic  report,  344  1 

radical  or  palliative,  319 
pathology,  288 
resection  for,  287 
symptoms,  286 
ulcer  and,  286 
contents,  bacteriologj-,  17 
dilatation,  post-operative,  90 
pathology,  92 
symptoms,  90 
theories,  93 
treatment,  96 
diseases,      chronic,      operations     in, 

indications,  288 
gunshot  wounds,  369 

haemorrhage  from,  370 
injuries   to   other   organs,    373, 
374 


Gastric  cancer,  gunshot  wounds,  mor- 
tality, 372 

nature  of  lesion,  370 
operation  in,  drainage,  374 
indications,  369 
position  of  patient,  374 
technique,  372 
peritonitis  from,  371 
spontaneous  recovery,  371 
lymphatics,  290 
areas  of,  292,  296 
associated  -ndth  cceliac   axis,    297 
with  coronary  artery,  292 
"n-ith  hepatic  artery,  294 
with  pyloric  artery,  294 
with  right    gastroduodenal   ar- 
tery, 294 
gastro-epiploic  artery,  294 
with  splenic  artery,  296 
cancer  invasion  of,  298 
direction  of  drainage,  291,  292 
distribution,  291,  292 
isolated  area,  296,  297 
primary,  297 
retropyloric,  294,  295 
right  suprapancreatic,  294,  295 
secondary,  297 
subpyloric,  294 
suprapyloric,  294,  295 
watersheds,  291,  292 
operations,  163 
perforation,  chronic,  140 
prolapse,  150.     See  also  Gastroptosis 
stasis,  operation  in,  indications,  289 
sterility,  food  and,  19.  20 

operations  and,  22 
tumor,  operation  in,  indications,  289 
ulcer,  163 

adhesions  in,  treatment,  51 
chronic,  177,  240 
cancer  from,  286 
excision,  258.    See  also  Excision 

of  gastric  ulcer 
general  propositions,  261 
operations  for,  240 
indications,  288 
recurrence,  260 
perforating,  163 
acute,  163 

medical  treatment,  165 
chronic,  163,  164 
diagnosis,  165 


INDEX    OF    SUBJECTS — VOLUME    I 


481 


Gastric      ulcer,     perforating    chronic, 
gastro-enterostomy  in,   171 
induration  in,  169 
menstruation  and,  167 
operation  in,  167 
after-care,  172 
drainage,  170 
proctoclysis  after,  172 
toilet  of  peritoneum,  170 
proctoclysis  in,  172 
symptoms,  165 
gastro-enterostomy  in,  171 
medical  treatment,  165 
subacute,  163 

medical  treatment,  165 
ulceration    from    drinking    caustics, 
surgical  treatment,  254 
Gastro-anastomosis       for       hour-glass 

stomach,  279,  281 
Gastroduodenal  artery,   right,    gastric 

lymphatics  associated  with,  294 
Gastro-duodenostomie  sous  pylorique, 

208 
Gastro-duodenostomy,   208,   240 
Finney's,  245 

Moynihan's  modification,  249 
Jaboulay's,  240 
Kocher's,  242 
Kiimmell's,  241 
lateral,  244 

Moynihan's  clamp  for,  251 
subpyloric,  241 
Villard's,  240,  241,  242 
Gastro-enterostomie  retrocolique  pos- 

terieure  transmesocolique,  208 
Gastro-enterostomy,  177 
adhesions  after,  217 
advantages   of   partial   gastrectomy 

over,  328,  329 
and  jejunostomy  combined,  209 
anterior,  197 

complications  after,  202 
in  Y,  198,  200 
jejunal  ulcer  after,  219 
retrocolic,  208 
Roux's,  198,  200 
antiperistaltic,  197 
appendectomy  with,  221 
Brenner's,  208 
by  invagination,  209 
Chlumskij's,  208 
complications  after,  202 

VOL.  I — 31 


Gastro-enterostomy,  Courvoisier's,  208 
diarrhoea  after,  236 
division    of    transverse    mesocolon, 

179,  180 
Doyen's,  209 
excision  of  gastric  ulcer  and,  choice 

between,  259 
Faure's,  209 

for  hour-glass  stomach,  278 
gastrojejunal  ulcer  after,  217 
gastrostomy  with,  256,  257 
haemorrhage  after,  203 
Hadra's,  210 

hernia  after,  internal,  211 
in  cancer,  mortality,  321 
in  duodenal  ulcer,  175 
in  gastric  cancer,  327 

mortality,  324 
in  perforating  ulcer,  171 
in  Y,  198,  200,  209 
indications,  259 
Jaboulay's,  208 
jejunal  ulcer  after,  217 
jejunostomy  with,  252 
Kader's,  208 
Kappeler's,  208 
modifications,  208 
Petersen's,  208 
position  after,  58,  203 
posterior,  177 

chief  points,  194 

complications  after,  202 

jejunal  ulcer  after,  219 

line    of    attachment    of    jejunum, 
196,  197 

Mayo's,  196,  197 

no-loop,  210 

size  of  opening,  195 

time  required  for,  193 
rapid  gastric  drainage  after,  238 
regurgitant  vomiting  after,  205 
results,  258 
retrocolic,  208 
Rockwitz's,  209 
Roux's,  198,  200,  209 
separation   of   united   viscera   after, 

217 
Sonnenburg's,  209 
stroma     situated     above     level     of 

gastric  contents,  239 
von  Hacker's,  208 
with  valve,  210 


482 


INDEX  OF  SUBJECTS — VOLUME  I 


Gastro-enterostom5^      Wolfler's,     208, 

2 10 
Gastro-epiploic      artery,     right,     gas- 
tric    lymphatics     associated     with, 
294 
Gastrogastrostomy       for       hour-glass 
stomach,  279,  281 
Watson's,  282 
Gastrojejimal     ulcer,    217.     See     also 
Jejunal  idcer 
case,  233 

transgastric  excision,  233 
Gastropexy,  150 
Beyea's,  155,  156 
Bier's,  157 
Coffey's,  153,  154 
Davis',  152 
Buret's,  150 
Rovsing's,  152 
Gastroplasty   for   hour-glass   stomach, 
279,  280 
Kammerer's,  for  hour-glass  stomach, 
279,  280 
Gastroptosis,  150 

abdominal  belt  for,  150 
multiparous,  154 
operation  in,  150 
Beyea's,  155,  156 
Bier's,  157 
Coffey's  153,  154 
Davis',  152 
Duret's,  150 
Rovsing's,  152 
symptoms,  150 
virginal,  154 
Gastrostomy,  350 
Frank's,  360 

Kocher's  modification,  360 
gastro-enterotomy  with,  256,  257 
indications,  350 
Kader's,  357 
Senn's,  352 
Witzel's,  358 

Moynihan's  modification,  365 
Gastrosuccorrhoea,  93 
Gauze  drainage,  36 
care  of,  65 
mask,  26 
Gerard-Marchant's  hepatopexy,  160 
Glenard's  disease,  150 
Gloves,  29 

pricjcing  of,  30 


Greater     curvature,    invasion     of,     in 

gastric  cancer,  299 
Gunshot  wounds  of  abdomen,  116 
of  stomach,  369 

hccmorrhage  from,  370 
injuries   to   other   organs,    373, 

374 
mortality,  372 
nature  of  lesion,  370 
operation  in,  drainage,  374 

indications,  369 

position  of  patient,  374 

technique,  372 
peritonitis  from,  371 
spontaneous  recovery,  371 


Hadra's  gastro-enterotom^^  210 
Hagmatemesis,  post-operation,  85 

causes,  87 

onset,  86,  87 

symptoms,  86 

treatment,  89 
Haemorrhage  after  gastro-enterotomy, 
203 

causes,  204 

prevention,  204 
from   gunshot  wounds   of  stomach, 

370 
Halsted's  suture,  385 
Hands,  sterilisation  of,  27 
Harrington's  solution,  39 
Hepatic     artery,     gastric     h'mphatics 

associated  with,  294 
Hepatopexy,  classification  of  cases,  161 

Francke  s,  161 

Gerard-Marchant's,  160 

Leguens,  160 

Moynihan's,  161 

Pean,  160 

total,  160 
Hepatoptosis,  157 

abdominal  belt  for,  159 

classification  of  cases,  161 

complete,  158 

floating  lobe,  158,  159 

linguiform  lobe,  158,  159 

operation  in,  160 

partial,  158 

Riedel's  lobe,  158,  159 
High  sigmoid  colotomy,  419 
time  for,  425 


INDEX  OF  SUBJECTS — VOLUME  I 


483 


Hernia,    internal,    after    gastro-enter- 
ostomy,  21 1 
prevention,  216 
Richter's  inversion  in,  469 
strangulated,  enterectomy  for,  453 
Hour-glass  stomach,  276 
acquired,  276 
causes,  276 
congenital,  276 
digital  divulsion  for,  283 
double  stenosis,  278 
gastrectomy  for,  partial,  279,  283 
gastro-anastomosis  for,  279,  281 
gastro-enterostomy  for,  278 
gastrogastrostomy  for,   279,   281 
gastroplasty  for,  279,  280 
Kammerer's    operation    for,    279, 

280 
operations  for,  276 
site  of  stricture,  276 
types,  277 
Hyperleucocytosis,    artificial,    as    pro- 
phylactic for  peritonitis,  67 


Ileosigmoidostomy,    Murphy    button 

in,  435 
Immediate  adenopathies,  298 
Incisions,  abdominal,  105 

of    peritoneum    between    clip    and 

forceps,  107 
size,  107 
suture,  107 
Inguinal  colotomy,  417,  418 

short  mesentery,  430 
Inoculations  to  prevent  post-operative 

peritonitis,  67 
Instruments,  sterilisation,  34,  50 
Intestinal  contents,  sterility,   18 
localisation,  375 
obstruction,    Moynihan's    tube    for, 

407 
suture,  384.     See  also  Suture,  intes- 
tinal 
Intestines,  bacillus  coli  in,  17 
prodigiosus  in,  19 
bacteriology,  1 7 
evacuation,  in  peritonitis,  125 
injury  to,  in  abdominal  wounds,  114, 

"5 
invasion  in  gastric  cancer,  300 
length,  455 


Intestines,  localisation,  375 
normal  arrangement,  375 
operations  on,  375 
small,  acute  obstruction  of,  resection 
for,  453 
drainage,  410 
gangrene  of,  enterectomy  for,  453 

inversion,  469' 
growths  of,  resection  for,  441 
isolation,  442 
length,  455 
operations  on,  375 
resection,  441 

after-treatment,  460 
shape,  378 

tuberculovis  disease,  450 
wounds  of,  operation  for,  470 
sterility  of,  food  and,  19,  20 
operations  and,  22 
streptococci  in,  18 
suture,  384.      See  also  Suture,  Intes- 
tinal 
Invagination,   gastro-enterostomy  by, 

209 
Isoform  for  rendering  intestinal   con- 
tents sterile,  23 
Isolated   lymphatic   area   of   stomach, 

296,  297 
Isolation  of  operative  area,  49 


Jaboulay's  gastroduodenostomy,  240 

gastro-enterostomy,   208 
Jejunal  ulcer,  217 

after  operation  for  carcinoma,  218 

cases,  223 

cause,  220 

clinical  types,  221 

operation  for,  229-233 

site,  218 

time  of  appearance,  219 

treatment,  223 

two  perforations,  219,  220,  236 
Jejunostomy,  363 

and    gastro-enterostomy    combined, 

209 
feeding  after,  368 
gastro-enterostomy  with,  252 
in  cancer,  329 
indications  for,  363 
Maydl's,  364,  365 
Robson's,  367 


484 


INDEX    OF    SUBJECTS VOLUME    I 


Kader's  gastro-enterostomy,  208 
gastrostomy,  357 

Kammerer's    gastroplasty    for    hour- 
glass stomach,  279,  280 

Kappeler's  gastro-enterostomy,  208 

Kidney  T\-ounds,  115 

Kocher's  gastroduodenostomy,  242 
method    of    uniting    duodentmi    to 

stomach  wall,  315,  316 
modification  of  Frank's  gastrostomy, 
360 

Kummell's    gastroduodenostomy,    241 


Laparotomy,  examination  after,  49 
exploratory,  in  gastric  cancer,   324, 

327 
Lateral    anastomosis.    433.     See    also 

Entero-ayvjstoinosis 
Lavage     in     penetrating     wounds     of 

abdomen,  116 

saline,  to  prevent  peritonitis,  71 
Leguen's  hepatopexy,  160 
Lembert's  suture.  384 
Lesser  cun.'ature.  invasion  in  gastric 

cancer,  299 
Levy's   operation   for   cardiac   cancer, 

330 
Ligation  of  omentum,  442 
Ligattues,  catgut,  34 

Pagenstecher's   celluloid  thread,    35 
silk,  35 

sterilisation,  34 
LiUenthaVs  colotomy,  430 
Lingiaiform  lobe,  158,  159 
Liver  prolapse,    157.     See    also  Hepa- 
topiosis 
suspensory  apparatus,  158 
wounds,  115 
Loop-on-mucosa  suture,  403 
Low  sigmoid  colotomy,  425 
Lumbar  colotomy,  417,  418,  428 
drainage  in,  429 
short  colon  in,  429 
Lunettes  of  mesentery,  378 
Lung    complications    after    operation, 
causes,  73 

treatment,  77 
of  abdominal  operations,  73 
Lymphatics  of  stomach,  290 
areas,  292,  296 
associated  with  cceliac  axis,  297 


Lymphatics     of     stomach     associated 
with  coronary  artery,  292 
with  hepatic  artery,  294 
with  pyloric  artery,  294 
with   right    gastroduodenal   ar- 
ter}",  294 
gastro-epiploic  artery,  294 
with  splenic  artery,  296 
cancer  invasion,  298 
distribution,  291,  292 
isolated  area,  296,  297 
primary,  297 
retropyloric,  294,  295 
right  suprapancreatic,  294,  295 
secondarj',  297 
subpyloric,  294 
suprapjdoric,  294,  295 
paracardial,  293 


Mackintoshes  during  operations,    32 
Massage  after  operation,  64 
Maunsell's  suture,  388 
Maydl's  jejunostomy,  364,  365 
Mayo's  posterior  gastro-enterostomy, 

196,  197 
Mesentery,  characters,  378 

lunettes,  378 

normal  arrangement,  375 

primary  loops,  379 

secondary  loops,  379 

tertiary  loops,  379 

vasa  recta,  378,  379 

vessels,  379 
Mesocolic  band,  179 
Mesocolon,     transverse,     division     of, 

179,  180 
Michel's  clips,  no 
Mitchell  and  Hunter's  suture,  470 
Mixter's  tube  in  enterostomy,  412 
Morphine  after  operation,  62 

and  scopolamine  anaesthesia,  44 
Moschowitz's  modification  of  Claudius' 

catgut  sterilisation,  35 
Mouth,  care  of,  after  operation,  64 

sterilisation,  37,  38 
Moynihan's  clamps,  180 

for  partial  gastrectomy,  306 

continuous  suture,  400,  401 

gastroduodenostomy  clamp,  251 

gastro-enterostomy     with     jejunos- 
tomv,  2.!;  3 


INDEX   OF    SUBJECTS — VOLUME    I 


485 


Moynihan's  hepatopexy,  161 

modification  of  Finney's  gastroduo- 
denostomy,  249 
of  Witzel's  gastrostomy,  365 
tube  for  intestinal  obstruction,  407 
Mural  cancer,  operation  in,  choice,  329 
Murphy  button,  404 

in  ileosigmoidostomy,  435 
continuous  proctoclysis  after  gastric 

ulcer  operation,  172 
indications  in  operation  for  tubercu- 
lous peritonitis,  133 
proctoclysis,  60 
rubber  dam,  40 
Muscular  fibres,  division  of,  in  incising, 

105 


"  Natural  cure"  of  bladder  stones,  52 
Nerve  division  in  incising,  105 
Nitrous  oxide  anaesthesia,  44 
Novocaine  anaesthesia,  43,  44,  46 
Nuclein     as     prophylactic     for     post- 
operative peritonitis,  67,  68 


Obstruction,  acute,  of  small  intestine, 

resection  for,  453 
CEdema  of  lungs  after  operation,  73,  76 
Omentum  ligation,  442 
Operating  room,  41 
Operative  area,  sterilisation,  38 


Pagenstecher's   celluloid  thread,    35 
Pain  after  operation,  62 
Paquelin  cautery  in  colotomy,  425 
Paracardial  lymphatic  glands,  293 
Paraffin  to  prevent  adhesions,  135 
Parker-Kerr  clamp,  Moynihan's  modi- 
fication, 306 
closure  of  distal  end  of  duodenum  in 

partial  gastrectomy,  306 
Parotitis,  post-operative,  79 

bacteriology-,  84 

causes,  80 

duct-infection  theory,  82 

embolic  theory,  80 

pyaemic  theory,  80 

reflex  theory,  81 

sympathetic  theory,  81 

theories,  80 


Patient,  preparation,  37 
Pauls  tube  in  colotomy,  417 

in  enterostomy,  412 
Pean's  hepatopexy,  160 
Penetrating  wounds  of  abdomen,   114 
drainage,  116,  117 
intestinal  injury  in,  114 
lavage  in,  116 
operation  for,  115 
viscera  injured,  114 
Perforating  ulcer,  163.   See  also  Gastric 
ulcer  and  Duodenal  ulcer 
wounds  of  abdomen,  114.     See  also 
Penetrating  wounds  of  abdomen 
Perforation,  gastric,  chronic,  140 
Perigastric  abcess,  140 
Peristalsis    after    operation    for    peri- 
tonitis, 125 
Peritoneum,  incision,  107,  108 
Peritonitis,    acute,    bowel    evacuation 
in,  125 
classification,  119 
diagnostic  value  of  escaping  fluid, 

120 
distension  in,  124,  125 
operation  in,  119 
after-care,  125,  126 
cleansing  peritoneum,  122,  123 
collapse,  126 

diagnostic  points  during,  120 
drainage,  122,  123,  124,  127 
examination,  121 
indications,  119 
lavage,  122,  123 
peristalsis  after,  125 
position  after,  125,  126 
preparation  of  patient,  120 
purposes,  119 
saline  infusion  after,  126 
technique,  120 
treatment,  surgical,  119 
Witzel  fistula  in,  125 
from   gunshot   wounds   of   stomach, 

371 
post-operative,  66 

bowels  in,  72 

preventive  inoculations,  67 
reopening  abdomen  for,  72 
symptoms,  71 
treatment,  72 
tuberculous,  128 
ascitic  form,  128 


486 


INDEX  OF  SUBJECTS — VOLUME  I 


Peritonitis,  tuberculous,  operation  in, 

134 
evacuation  of  fluid,  cure  b5^   135, 

136 
fibrous  form,  129,  130,  131 
operation  in,  133 
adhesions,  135 
advantages,  130 
indications,  130,  133 
results,  130,  131 
technique,   134 
removal  of  Fallopian  tube,  134 
spontaneous  recovery,  130,  131 
suppurative  form,  129,  130,  132 
Petersen's  gastro-enterostomy,  208 
Phlebitis,  post-operative,  96 
Pituitary  extract  for  flatulence,  63 
Pleura     involvement     in     subphrenic 

abscess,  142 
Pleurisy  after  operation,  73,  75,  78 
Pneumonia  after  operation,  73,  75,  78 
Position  after  operation,  58 
Preparations  for  abdominal  operations, 

24 
Proctoclysis,  60 

Murphy's,  after  gastric  ulcer  opera- 
tion, 172 
Prolapse,  visceral,  surgical  treatment, 

150 
Pulmonary  embolism  after  operation, 

73.  75.  78 
gangrene  after  operation,  73 
Pyaemic  theory  of  secondary  parotitis, 

80 
Pylorectomy  for  cancer,  318 
Pyloric     artery,      gastric     lymphatics 
associated  with,  294 
cancer  of,  mode  of  spreading,   297, 
298 
operation  in,  choice,  318 
stenosis,  177 
ulcer,  infolding,  192 
Pyloroplasty,  Finney's,  245 

Quinine  and  urea  hydrochloride  anai's- 
thesia,  44,  46 

Rectal  injections  after  operation,  60 
Reflex  theory  of  secondary  parotitis,  81 
Regurgitant     vomiting    after    gastro- 
enterostomy, 205.   See  also  Vomiting, 
regurgitant,    after    gastro-enterostomy 


Retropyloric  lymphatics,  294,  295 
Richter's  hernia,  inversion  in,  469 
Riedel's  lobe,  158,  159 

abdominal  belt  for,  159 

treatment,  159,  160 
Robsons  jejunostom)^  367 
Rockwitz's  gastro-enterostomy,  209 
Roux's  gastro-enterostomy,  209 

anterior,  198,  200 
Rovsing's  gastropexy,  152 
Rubber  dam,  40 
tube  drainage,  37 


Saline  infusion,   continuous  subcuta- 
neous, 126 
injections  after  operation,  60 
lavage  to  prevent  peritonitis,  71 

Sequels  of  abdominal  operations,  66 

Senn's  gastrostomy,  352 

Shockless  operation,  43,  62 

Short-circuiting,  433.    See  also  Entero- 
anastomosis 

Sigmoid  colotomy,  high,  419 
time  for,  425 
low,  425 

Silk  ligatures,  35 

Silkworm-gut  sutures,  108 

Skin,  sterilisation  of,  38,  48,  49 

Small  intestine.      See   Intestine,   small 

Sonnenberg's  gastro-enterostomy,   209 

Spectacle  mask,  25 

Spermin   injections   to   prevent    post- 
operative peritonitis,  67 

Spleen  wounds,  115 

Splenic     artery,     gastric     Ij^mphatics 
associated  with,  296 

Splitting  muscular  fibers,  105 

Stenosis,  pyloric,  177 

Sterilisation  of  catgut,  34 
of  gloves,  29 
of  hands,  27 
of  instruments,  34,  50 
of  ligatures,  34 
of  mouth,  37,  38 
of  operative  area,  38,  48,  49 
of    Pagenstecher's   celluloid   thread, 

35 
of  swabs,  31,  50 
Sterility  of  alimentary  canal,  food. and, 

19,20 
of  intestinal  contents,  18 


INDEX  OF  SUBJECTS — VOLUME  I 


487 


Sterility  of  intestines,  operations  and, 
22 

of  stomach,  operations  and,  22 
Stomach.     See  Gastric 
Stomach-tube  in  oesophagus  in    total 

gastrectomy  operation,  344 
Strangulated  hernia,  enterectomy  for, 

453 
Streptococci  in  intestinal  canal,  18 
Stricture  of  small  intestinal,  resection 

for,  441 
Subcutaneous  saline  infusion,   contin- 
uous, 126 
Subphrenic  abscess,  137,  164 

age  and,  147 

aspiration  in,  142,  149 

bacteriology  of  pus,  148 

diagnosis,  141 

extra-peritoneal,  137 

fossae,  14s 

gas  in,  141 

incision  along  lower  costal  margin, 

143 
through      anterior      abdominal 

wall,  143 
through     chest-wall     and     dia- 
phragm, 143 
through   thorax  and   abdomen, 

144 
transpleural,  143 
intraperitoneal,  137 
mortality,  145,  149 
onset,  148 
operation  in,  143 
incisions  for,  143 
results,  145 
origin,   138 
physical  signs,  141 
pleuritic  effusion  in,  142 
retroperitoneal,  141 
rigors  in,  148 
sex  and,  147 
source,  146 

spontaneous  rupture,  147 
Subpyloric  lymphatics,  294 
Suppurative    tuberculous    peritonitis, 

129,  130,  132 
Suprapancreatic     gastric     lymphatics, 

294,  295 
Suprapyloric  lymphatics,  294,  295 
Surgeon,  preparations,  24 
Sutures,  abdominal,  108 


Sutures,  buried,  catgut  for,  i  j  i 

materials  for,  1 1 1 
Connell's,  391 

continuous,  objections  to,  399 
Cushing"s,  387 
Dupuytren's,  385,  386 
Halsteds,  385 

interrupted,  objections  to,  398 
intestinal,  384 

best  method,  400 

Connell's,  391 

continuous,  398 

Cushing's,  387 

Dupuytren's,  385,  386 

Halsted's,  385 

interrupted,  398 

Lembert's,  384 

Maunsell's,  388 

Moynihan's,  400,  401 

through-and-through,  388 

two  continuous,  400,  401 
Lembert's,  384 
loop-on-mucosa,  403 
Maunsell's,  388 
Mitchell  and  Hunter's,  470 
Moynihan's,  400,  401 
of  abdominal  wall,  109 
of  incisions,  107 
silkworm-gut,  108 
through-and-through,  388 
Ward's,  in  colotomy,  421,  422,  429 
Swabs,  31,  50 

left  in  abdomen,  32,  33 
Sympathetic  theory  of  secondary  paro- 
titis, 81 

Teeth,  toilet  of,  after  operation,  64 
Tetra  cloths,  39,  40,  49 
Thirst,  58 

Thrombophlebitis,    frequency,    97,    98 
post-operative,  96 

bacterasmia,  103 

causes,  96 

clinical  course,  99 

disintegration   of   corpuscles,    102 

infected  cases  and,  100 

injury  to  vascular  walls,  102 

slowing  of  blood  stream,  102 

symptoms,  99 

treatment,  103 

veins  most  frequently  affected,  98 
Thrombosis,  post-operative,  96 


488 


INDEX   OF    SUBJECTS — VOLUME    I 


Through-and-through  suture,  388 
Towels,  34 

Transgastric  excision  of  gastrojejunal 
ulcer,  233 
of  ulcer,  269,  270 
Transverse     mesocolon,     division     of, 

179,  180 
Treatment  of  adhesions,  51 
Tuberculosis  of  small  intestine,  450 
Tuberculous  peritonitis,  128.     See  also 

Peritonitis,  tuberculous 
TyphlotomA^  411,  412 

Ulcer,   duodenal,    163.     See  also -Dxio- 
denal  ulcer 

gastric,  163.   See  also  Gastric  ulcer 

gastrojejunal,   217.    See  also  Gastro- 
jejunal ulcer 

jejxonal,  217.   See  also  Jejunal  ulcer 
Ulceration      gastric,     from     drinking 

caustics,  siirgical  treatment,  254 
Ulcerative,      tuberculous      peritonitis 

129,  130,  132 
Urination  after  operation,  60 

Vasa  recta  of  mesentery,  378,  379 
Vena  cava  as  support  of  liver,  158 


Villard's     gastroduodenostomy,      240, 

241,  242 
Viscera  injured  in  penetrating  wounds, 

114 
Visceral  prolapse,   surgical  treatment, 

150 
Vomiting,    regurgitant,    after    gastro- 
enterostomy, 205 

causes,  207,  210 

frequency,  207 

modifications  to  prevent,  208 

narrowing  afferent  loop  for,  209 

theories,  205 

treatment,  211 

varieties,  207 
von  Hacker's  gastro-enterostomy,  208 

Ward's  suture  in  colotomy,  421,  422, 

429 
Watson's  gastrogastrostomy,  282 
Witzel  fistula  in  peritonitis,  125 
gastrostomy,  358 

Moynihan's  modification,  365 
Wolfier's  gastro-enterostomy,  208,  210 
Woiuids  of  abdomen,  penetrating,  114. 
See  also  Penetrating  wounds  of  ab- 
domen 


Date  Due 

'^->-33 

/-n-yi 

l-27r3^ 

^        f 

FFR  2n 

:_vf 

«AAflt 

iBWi 

-  i>  ?948 

^ 

RD640 
Moynihan 


M87 

1914 

v.l. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  540  MS?  1914  C.2  V.  1 


2002246996 


^■. 


L 


